Major complications of untreated or advanced HIV

1. Serious infections, often the main cause of death

• Tuberculosis (TB): Can affect lungs or spread throughout the body. It is a leading cause of death in people with HIV worldwide.
• Severe bacterial infections: Pneumonia, bloodstream infection (sepsis), meningitis, and recurrent severe infections.
• Pneumocystis pneumonia (PCP): Causes progressive breathlessness, low oxygen, and respiratory failure.
• Cryptococcal meningitis: A fungal infection of the brain coverings causing headache, fever, confusion, raised brain pressure, coma, and death if untreated.
• Toxoplasmosis of the brain: Can cause seizures, weakness, confusion, or coma.
• Disseminated fungal infections: Such as histoplasmosis, which can affect many organs.
• Cytomegalovirus (CMV): May cause blindness from retinitis, colitis, or brain disease.
• Chronic severe diarrheal infections can lead to dehydration, malnutrition, and electrolyte disturbances.

2. Cancers associated with immune suppression

• Kaposi sarcoma, which can affect skin, lungs, or gastrointestinal tract.
• Non-Hodgkin lymphoma, including lymphoma involving the brain.
• Cervical, anal, liver, and other cancers may occur more often or behave more aggressively.

3. Organ and systemic complications

• HIV-related kidney disease and kidney failure
• Heart disease, stroke, and blood clots
• Liver disease, particularly with hepatitis B or C co-infection
• Severe weight loss and muscle wasting
• Anemia and low blood cell counts
• Nerve and brain problems, including cognitive decline, depression, confusion, and HIV-related encephalopathy

How a patient with advanced HIV may die

1. Respiratory failure from PCP, severe bacterial pneumonia, TB, or lung involvement by cancer.
2. Sepsis and shock from overwhelming bacterial, fungal, or mycobacterial infection. Blood pressure falls and multiple organs fail.
3. Meningitis or encephalitis from cryptococcus, TB, toxoplasmosis, or other infections, leading to seizures, coma, or raised pressure in the brain.
4. Disseminated TB or fungal infection, causing failure of several organs.
5. Cancer progression, bleeding, airway obstruction, organ failure, or infection related to cancer or chemotherapy.
6. Severe malnutrition, dehydration, or organ failure in very late untreated disease.

Important: HIV is now treatable

Major complications of untreated or advanced HIV

1. Serious infections, often the main cause of death

• Tuberculosis (TB): Can affect lungs or spread throughout the body. It is a leading cause of death in people with HIV worldwide.
• Severe bacterial infections: Pneumonia, bloodstream infection (sepsis), meningitis, and recurrent severe infections.
• Pneumocystis pneumonia (PCP): Causes progressive breathlessness, low oxygen, and respiratory failure.
• Cryptococcal meningitis: A fungal infection of the brain coverings causing headache, fever, confusion, raised brain pressure, coma, and death if untreated.
• Toxoplasmosis of the brain: Can cause seizures, weakness, confusion, or coma.
• Disseminated fungal infections: Such as histoplasmosis, which can affect many organs.
• Cytomegalovirus (CMV): May cause blindness from retinitis, colitis, or brain disease.
• Chronic severe diarrheal infections can lead to dehydration, malnutrition, and electrolyte disturbances.

2. Cancers associated with immune suppression

• Kaposi sarcoma, which can affect skin, lungs, or gastrointestinal tract.
• Non-Hodgkin lymphoma, including lymphoma involving the brain.
• Cervical, anal, liver, and other cancers may occur more often or behave more aggressively.

3. Organ and systemic complications

• HIV-related kidney disease and kidney failure
• Heart disease, stroke, and blood clots
• Liver disease, particularly with hepatitis B or C co-infection
• Severe weight loss and muscle wasting
• Anemia and low blood cell counts
• Nerve and brain problems, including cognitive decline, depression, confusion, and HIV-related encephalopathy

How a patient with advanced HIV may die

1. Respiratory failure from PCP, severe bacterial pneumonia, TB, or lung involvement by cancer.
2. Sepsis and shock from overwhelming bacterial, fungal, or mycobacterial infection. Blood pressure falls and multiple organs fail.
3. Meningitis or encephalitis from cryptococcus, TB, toxoplasmosis, or other infections, leading to seizures, coma, or raised pressure in the brain.
4. Disseminated TB or fungal infection, causing failure of several organs.
5. Cancer progression, bleeding, airway obstruction, organ failure, or infection related to cancer or chemotherapy.
6. Severe malnutrition, dehydration, or organ failure in very late untreated disease.

Important: HIV is now treatable

• Trouble breathing, blue lips, or chest pain
• Confusion, fainting, seizures, weakness on one side, or reduced consciousness
• Severe headache with fever, vomiting, or neck stiffness
• Persistent high fever, inability to drink, severe diarrhea, or very little urine
• Coughing blood or rapid worsening weakness

Key WHO recommendations

• Identify advanced HIV disease with CD4 testing: WHO now recommends CD4 count as the preferred method. Advanced HIV disease is generally a CD4 count below 200 cells/mm³ or WHO clinical stage 3 or 4 illness.
• Use clinical staging only where CD4 testing is unavailable: This is a conditional recommendation because clinical staging alone can miss cases or misclassify people.
• Give every person with advanced HIV a package of care:
  • screen for major opportunistic infections
  • treat confirmed infections
  • provide preventive treatment when indicated
  • initiate ART rapidly when clinically safe
  • provide enhanced adherence support, including counselling, follow-up contacts, and where needed home-based or palliative support.
• Prioritize screening for major causes of death: especially tuberculosis, severe bacterial infections, cryptococcal meningitis, and, depending on setting, histoplasmosis.
• Start ART rapidly in most people, but do not apply a one-size-fits-all approach:
  • With most infections, ART is begun promptly after assessment and initial treatment.
  • With cryptococcal meningitis, ART should generally be deferred for 4 to 6 weeks after antifungal treatment begins.
  • With TB meningitis, ART should generally be deferred until after about 4 weeks of TB treatment.
  • This avoids dangerous immune reconstitution inflammatory syndrome in infections affecting the brain.
• Recognize serious illness urgently: WHO highlights danger signs including respiratory rate at least 30/minute, heart rate at least 120/minute, or inability to walk unaided. These patients need rapid hospital assessment.

• Note the exact time the speech became abnormal or when the patient was last known well. This affects stroke treatment options.
• Keep them sitting upright if breathless, unless they become faint or unresponsive.
• Do not give food, water, alcohol, or tablets by mouth, because swallowing may be unsafe.
• Do not give aspirin unless emergency clinicians specifically instruct it, since some strokes are caused by bleeding.
• Do not let them walk, drive, or stay alone.
• If possible, bring their medication list, HIV/ART details, allergies, and medical records.
• If they become unconscious but are breathing, place them on their side. If they are not breathing normally, start CPR if you know how and follow the emergency dispatcher’s instructions.

• Keep the patient still. Do not let them stand, walk, or drive.
• Assume a neck/spine injury is possible. Keep the head and neck in a neutral position. Do not twist, massage, or move the neck/back unless there is immediate danger.
• If breathless, keep them as upright as possible without moving the neck or back. Support the head and neck.
• Do not give food, drink, alcohol, aspirin, ibuprofen, blood-thinning medicines, or sleeping tablets.
• If there is bleeding from the scalp, press a clean cloth gently over the wound. Do not press hard if there is a depression in the skull, bone visible, or fluid/blood from the ears or nose.
• If they vomit, are drowsy, or unconscious but breathing, carefully roll the entire body onto one side as a unit, keeping head, neck, and spine aligned.
• If they are not breathing normally, begin CPR and follow the emergency dispatcher’s instructions.
• Note the time of the fall and when the slurred speech began. Bring medication details, especially any blood thinners, ART/HIV medicines, allergies, and prior illnesses.

• Record the exact time the patient was last speaking normally or the time symptoms began.
• Keep them still. Do not allow walking or driving.
• Protect the neck and back. Avoid moving the head or neck unnecessarily.
• Nothing by mouth: no food, water, tablets, aspirin, ibuprofen, or alcohol. Aspirin can be dangerous if there is bleeding in the brain.
• If they are sleepy or vomit but are breathing, turn the whole body onto one side while keeping the head, neck, and spine aligned.
• If unconscious and not breathing normally, start CPR and follow the ambulance dispatcher’s instructions.
• Bring details of medicines, especially blood thinners, HIV medicines, diabetes or blood-pressure medicines.

• B - Balance: sudden dizziness, inability to walk, falling, loss of coordination.
• E - Eyes: sudden loss or blurring of vision, double vision, or loss of vision in one eye.
• F - Face: new facial droop or uneven smile. Ask them to smile.
• A - Arm: sudden weakness, numbness, or drifting down of one arm or leg. Ask them to raise both arms.
• S - Speech: slurred speech, wrong words, inability to speak, or difficulty understanding. Ask them to repeat a simple sentence.
• T - Time: record the exact time they were last normal and call an ambulance.

• Sudden severe headache, especially with vomiting
• New confusion, unusual drowsiness, fainting, or reduced consciousness
• Seizure
• Repeated vomiting
• New difficulty swallowing, choking, or drooling
• Worsening breathlessness or chest pain

“Head injury from a fall 4 days ago. Now has slurred speech, breathlessness, and leg swelling. Concern for delayed brain bleed or stroke.”

• Keep them still and do not allow them to walk or drive.
• Do not give aspirin, ibuprofen, diclofenac, or blood-thinning medicine unless a clinician has directed it.
• Do not give food, drinks, or oral medicines if speech is slurred or swallowing is uncertain.
• Bring details of all medicines, especially blood thinners, blood pressure medicines, and HIV treatment.
• Note when the slurred speech was first noticed and when they were last known to be normal.