By Reuben Granich, Marco Vitoria, and Craig McClure (HIV/AIDS Department, WHO, Geneva)
Despite considerable progress, the global HIV situation remains serious. By the end of 2009, 5.2 million people were on antiretroviral treatment (ART); approximately 36 per cent of those estimated to be in need as per the new WHO recommendations. This, combined with the international fiscal crisis, has led to a growing concern regarding a weakening of the international commitment to universal access and to reaching the related Millennium Development Goals (MDG) by 2015. However, there are a number of reasons to be optimistic about our future efforts to confront HIV.
The 5.2 million people on treatment are a remarkable testament to the many outstanding examples of programmes that are doing great work on a large scale. However, our current response to HIV is often fragmented and unnecessarily complicated. This complexity often means late initiation of treatment, lack of continuum of care and increased costs for both programmes and patients. Retention of patients on antiretroviral therapy, which can mean the difference between life and death, is often hindered by our current approach to delivering treatment. Patients, where there is access to treatment, are often asked to travel great distances, wait in long queues, join lengthy waiting lists and return frequently to evaluate eligibility for treatment.
When placed on treatment, patients are often asked to adhere to difficult regimens with little hope of second line treatment in the case of toxicity or a failure to respond. Drug stock outs are also a stumbling block for adhering to ART programmes. Prevention, treatment, care and social support programmes are often in different locations and could be better integrated in order to effectively use scarce resources. There is a need to re-examine our approach to delivering prevention and treatment services to ensure easier access for people living with HIV.
Two key opportunities have the potential to hasten and expand the twin goals of saving lives and preventing new HIV infections. Firstly, the ongoing efforts to develop drug regimens and treatment strategies that will render HIV treatment easier to administer, more efficient to manage, and have a longer lasting impact for individuals and public health programmes. Secondly, it is also increasingly clear that universal access to ART can have a significant impact on HIV transmission. The potential individual and public health prevention benefits of treatment enhance the value of the universal access pledge from a life-saving initiative to a strategic investment aimed at ending the HIV epidemic.
‘Treatment 2.0’ was recently launched by UNAIDS and WHO to accelerate the simplification of ART in order to achieve and sustain universal access to treatment for all who need it and realize the significant potential for HIV and TB preventive benefits. The agenda of Treatment 2.0 involves radically simplifying drug regimens and diagnostics and monitoring, decentralizing service delivery, reducing costs and mobilizing communities.
When combined, expanding access to ART using simpler, more effective approaches and the use of ART as part of combination prevention will be critical in reaching the goals of universal access and will, most likely, result in cost savings over the medium and long term. Patient-friendly regimens should allow for improved adherence and increased access and retention to treatment. Our challenge is to understand how best to use new information regarding the role of ART for a reinvigorated, more effective and sustainable global response to AIDS. A simplified, public health approach to treatment is nothing new. WHO advanced this approach in 2003 to kick-start ART access in developing countries. Since then, the number of people on treatment has increased from 50,000 to over 5 million. What is potentially new is a renewed and intensified focus on simplification with accelerated expansion and full integration of treatment as a key aspect of HIV prevention efforts.
Article from IPPF HIV Update newsletter - Issue 24: http://www.ippf.org/en/Resources/Newsletters/HIV+Update+Issue+24.htm