By not preparing for the changing treatment needs of people living with HIV, the sustainability of treatment programmes in developing countries is doomed. Over the next decade, an increasing number of patients on inexpensive first-line antiretroviral (ARV) drugs in low-income countries will need second-line ARVs, which currently cost at least seven times more. Many patients will also need to be switched to newer, less toxic first-line drugs, which have fewer side-effects but are at least double the price. This report argues that action is needed now to bring down the price of second-line and less toxic first-line ARVs if a crisis is to be averted later. It supports an alternative approach that would see pharmaceutical companies putting their ARV patents into a single pool, from which manufacturers or researchers could draw in exchange for a royalty fee. Patent pools not only have the potential to reduce the price of existing ARVs, but can stimulate the production of urgently needed new medicines and formulations, such as paediatric ARVs and fixed-dose combinations.
Equity and HIV/AIDS
The main aims of PEPFAR are presented for information. PEPFAR seeks to ensure that HIV and AIDS programmes are sustainable, country-owned and country-driven. The programmes must address HIV/AIDS within a broader health and development context and must build on existing strengths and increase efficiencies. PEPFAR seeks to transit from an emergency response to promotion of sustainable country programmes, strengthening partner government capacity to lead the response to the epidemic and other health demands, expanding prevention, care and treatment in both concentrated and generalised epidemics, integrating and coordinating HIV and AIDS programmes with broader global health and development programmes to maximise impact on health systems, and investing in innovation and operations research to evaluate impact, improve service delivery and maximise outcomes. PEPFAR’s targets for the fiscal period 2010–2014 focus on prevention, care, support, treatment and sustainability, including supporting the training and retention of more than 140,000 new health care workers to strengthen health systems.
According to Peter Salama, head of the United Nations Children’s Fund (UNICEF) in Zimbabwe, between 6, 000 and 7,000 children die per year in Zimbabwe as a result of HIV and in most cases it is because these children have failed to access paediatric anti-retroviral therapy (ART). The lack of technology meant that many children were not being tested for HIV, Salama said at an AIDS conference in Harare in September 2011. ‘It is important to have an early infant diagnosis as 50% of those children not tested will not be able to reach the age of two,’ he added. About one in seven Zimbabweans is infected with HIV, and about 13% of pregnant women are HIV-positive in Zimbabwe. However, the relatively high costs of medical care and the poor economy means many women give birth at home or never return to hospital for post-natal checkups.
In this article, the authors summarise the main points of the UNAIDS World AIDS Day Report 2012 (included in this newsletter), which evaluated global progress in reaching the goals of Zero New HIV Infections, Zero Discrimination and Zero AIDS-Related Deaths. While the report includes quantitative information on two of the “Getting to Zero” goals – zero new infections and AIDS-related deaths – there is very little information on the third - zero discrimination - the authors note. Challenges persist in treatment and prevention, and progress is further impacted on by politics, poor governance, prohibitive costs and failure to build on evidence in the multisector response. Despite the flagging global response, countries have managed to move ahead, albeit slowly, to treat HIV-affected people, prevent transmission from mother to child and promote safe sexual behaviour. With treatment now available for only US$100 annually in some countries, the authors argue it is time for another bold move such as 3 by 5, focused on direct support to countries and a more strategic and efficient allocation of global resources toward evidence-based strategies that have been shown to work.
At the close of the 16th International AIDS Conference in Toronto, Canada, the pervading mood was one of guarded optimism. The conference theme, 'Time To Deliver', set the tone for a week of reflection on lessons learned from the past 25 years of the AIDS epidemic. UN Special Envoy for HIV/AIDS in Africa Stephen Lewis used it as a rallying call in his closing speech to define the needs of the next 25 years, with a special focus on prevention.
Despite the successes in rolling out antiretroviral therapy in sub-Saharan Africa, treatment remains lifelong and systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programmes. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programmes in Africa. They interviewed 890 patients enrolled in HIV treatment programmes in Jos in Nigeria, Dar es Salaam in Tanzania and Mbarara in Uganda who had extended absences from care. Two-hundred-eighty-seven were located, and 91 took part in the study. Findings revealed unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Through the process of disengagement, patients who missed visits and felt reluctant to return over time lost their subjective sense of connectedness to care. The authors conclude that efforts to prevent missed clinic visits combined with moves to minimise barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.
This DFID paper looks at information and evidence for the global prevalence of HIV stigma and how it damages people living with HIV and AIDS and their families, especially women. It provides information and evidence on: HIV stigma is globally prevalent and damaging—affecting people living or associated with HIV and AIDS on a daily basis—and is especially severe for women; HIV stigma compromises effective responses to AIDS (by lowering uptake of preventive services and testing, delays disclosure, decreases care seeking and undermines treatment; effective strategies for tackling stigma exist, and action is possible; and DFID is well placed to help scale-up efforts and play a leading role in the international arena.
Sub-Saharan Africa alone contributes more than 90 % of global Mother-to-Child Transmission (MTCT) burden. As part of efforts to address this, African countries were earmarked in 2009 for rapid Preventing Mother to child HIV Transmissions (PMTCT) interventions scale-up within their primary care system for maternal and child health. In this study, the authors reviewed records in Ghana, on ANC registrants eligible for PMTCT services to describe regional disparities and national trends in key PMTCT indicators. They also assessed distribution of missed opportunities for testing pregnant women and treating those who are HIV positive across the country. Although there was a decline in HIV prevalence among pregnant women, untested ANC registrants increased from 17 % in 2011 to 25 % in 2013. There were varying levels of missed opportunities for testing across the ten regions of Ghana. Overall, HIV positive pregnant women initiated onto ARVs remarkably increased from 57% (2011) to 82 % (2013). Missed opportunities to test pregnant women for HIV and also initiate those who are positive on ARVs across all the regions pose challenges to the quest to eliminate mother-to-child transmission of HIV in Ghana. For some regions these missed opportunities mimic previously observed gaps in continuous use of primary care for maternal and child health in those areas. The authors contend that increased national and regional efforts aimed at improving maternal and child healthcare delivery, as well as HIV-related care, is paramount for ensuring equitable access across the country.
A global shortage of funds for the fight against HIV means universal access to prevention, treatment and care is unlikely unless HIV programmes get better value for their investments, according to this report. It argues that there is a need to ‘enhance the impact of current investments by improving the efficiency, effectiveness and quality of programmes, strengthening links between programmes, and building systems for a sustainable response. Although 5.25 million people accessed life-prolonging antiretroviral medication in 2009 - up 1.2 million from 2008 - the report notes that funding shortages, limited human resources, weak procurement and supply management systems for HIV drugs and diagnostics, and other bottlenecks continued to hamper the scale-up of treatment. An estimated 53% of pregnant women worldwide in need of prevention of mother-to-child transmission services received them in 2009, but only 28% HIV-positive children received treatment in 2009, compared to 36% for adults, and just 15% of children born to HIV-positive mothers were given appropriate infant diagnostics.
This progress report from the World Health Organisation (WHO) shows a steady increase in the global levels of access to antiretroviral therapy (ART) for people living with HIV. However, it shows less improvement in other priority areas of HIV treatment. The coverage rate for access to prophylactic ART by pregnant women, to prevent mother to child transmission of the virus, continues to be low. Similarly, the coverage of HIV counselling services and of interventions directed at intravenous drug users (IDUs) also remain at a low level. The report shows some improvement in the effective monitoring of HIV prevalence.