Reflections from IPPF

By Anupam Pathni, Programme Officer – HIV and AIDS (IPPF South Asia Regional Office)

The World Health Organization (WHO) regularly releases updated clinical guidelines on the use of antiretroviral (ARV) drugs for adults and adolescents, and for maternal and child health. For the first time ever, WHO undertook a process of developing a set of consolidated guidelines that go beyond incorporating updated clinical guidance (‘what to do’), to include operational (‘how to do’) and programmatic (‘how to decide what to do, where and when’) guidance to help each country make the best decisions on the use of ARVs in their own context.

IPPF was involved as a civil society representative in the operational and service delivery guideline development group (GDG), and participated in the GDG meeting on 6-8 November 2012 in Geneva. Systematic and GRADE reviews of the operational issues being considered were presented. Participants reviewed risk/benefit tables and discussed various recommendations, covering the following topics: community based HIV testing and counselling, task shifting for ART, decentralization of HIV treatment, strategies for improving treatment adherence, integration of ART and HIV in TB treatment settings and vice versa, and integration of ART and HIV care in MNCH and opiate maintenance treatment settings. Based on the deliberations at this meeting and other similar meetings, the guidelines were updated and were launched at the end of June 2013.

These new guidelines have the potential to transform HIV responses in countries and to boost efforts to achieve ‘Universal Access’ targets. Though none of the IPPF Member Associations (MAs) in the South Asia Region are currently providing ART to their clients, all of the MAs play a very important role in supporting the efforts of their national governments in this area. While implementing community HIV testing and counselling strategies, it will be important for MAs to ensure adherence to rights-based principles beyond ensuring linkages with the continuum of care for those who are diagnosed HIV-positive. In tandem with the promotion of community-based HIV testing and counselling, IPPF needs to continue advocating for enabling environments to help treatment adherence, for example by advocating against punitive laws.

Provision of services cannot happen in isolation and needs to be balanced with community mobilization and context-specific demand creation strategies, which is one of the strengths of our MAs. The new WHO guidelines recommend task shifting and decentralization of HIV treatment and our MAs could leverage opportunities under their national programmes to ensure ART provision within their own facilities, or at the community level. A cross-cutting issue that needs to be addressed would be the implementation of efficient referral systems and linkages to support community-based HIV testing and counselling, decentralization, and integration of services.

Provision of services related to antiretroviral therapy by IPPF Member Associations

A total of 22 IPPF Member Associations reported providing ART-related services in 2012. In 2012, there was a large increase in the number of services provided, as well as facilitated referrals. This increase was largely due to increased ART service provision in Cambodia, Dominican Republic, Ethiopia, Indonesia, Sierra Leone, Sudan, and Togo; and referrals in India and Tanzania.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy

New WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection

By Dr Lisa Nelson, Medical Officer and Dr Gottfried Hirnschall, Director (HIV/AIDS Department, WHO, Geneva)

On June 30 2013, WHO released updated HIV guidelines on the diagnosis of HIV, the care of people living with HIV and the use of antiretroviral (ARV) drugs for treating and preventing HIV infection.  These guidelines were launched during the 7^th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) held in Kuala Lumpur, Malaysia from 30 June to 3 July 2013.

The document was developed in consultation with country policy makers and programme planners, implementers, researchers, clinicians, and affected communities. These guidelines are novel in several ways by:

1. harmonizing guidance and treatment regimens across populations, as well as along the continuum of care;
2. providing guidance on how to improve service delivery and to make decisions on optimal resource allocation; and
3. consolidating existing and new recommendations into a single document using a public health approach.  

Key data that prompted this update include evidence of the individual and population-level benefit of earlier treatment [1], more effective and simplified treatment approaches, new knowledge on effective service delivery models and new technologies such as point-of-care CD4 testing.

The new clinical recommendations in these guidelines promote early initiation of antiretroviral therapy (ART) at a CD4 threshold of 500 cells/mm3 or less for adults, adolescents and older children. Priority should be given to persons with severe or advanced HIV disease and those with CD4 count of 350 cells/mm3 or less. ART is recommended regardless of CD4 count for certain populations, including people with active tuberculosis (TB) disease who are living with HIV, people with both HIV and hepatitis B virus (HBV) with severe chronic liver disease, HIV-positive partners in serodiscordant couples, pregnant and breastfeeding women and children younger than five years of age. Harmonization of ART regimens for adults, pregnant women and children is recommended whenever possible, with a new, preferred first-line ART regimen of tenofovir/lamivudine or emtricitabine/efavirenz (TDF/XTC/EFV) as a fixed-dose combination tablet once daily. The need to phase out d4T in first-line ART regimens for adults and adolescents is being reinforced. Viral load testing is now recommended as the preferred approach to monitoring ART success and diagnosing treatment failure, complementing clinical and immunological monitoring of people receiving ART.

“These new guidelines have the potential to transform HIV responses in countries and to boost efforts to achieve ‘Universal Access’ targets, towards and beyond 15 million people on antiretroviral therapy in low- and middle-income countries by 2015.” Dr Gottfried Hirnschall 

For pregnant and breastfeeding women and children under age five living with HIV, the routine offer of ART irrespective of CD4 count or clinical stage will improve treatment access.  Current treatment coverage is unacceptably low for these groups.  Simplified approaches such as using a common regimen of TDF/XTC/EFV for all those eligible should also improve uptake.

The guidelines emphasize that ARV drugs should be used within a broad continuum of HIV care.  Additional new recommendations range from community-based HIV testing and counseling, to HIV testing of adolescents, and the use of post-exposure prophylaxis after sexual assault. Summaries and links to existing WHO guidance are provided for HIV testing and counselling, HIV prevention, general care for people living with HIV, the management of common co-infections and other comorbidities, and monitoring and managing drug toxicities.

Data on service delivery models were reviewed and a number of new evidence-based recommendations were developed including a recommendation to initiate ART in maternal and child health and tuberculosis treatment facilities in high burden settings.  ART should also be offered in care settings where opioid substitution therapy (OST) is provided.  Decentralization of services provides an opportunity to offer ART to more people closer to where they live.  Trained non-physician clinicians, midwives and nurses can initiate and maintain first-line ART (task shifting) and supervised community health workers can dispense ART between regular clinical visits.

These guidelines aim to assist countries in decision-making and programme planning, to adapt the recommendations for their epidemic, health systems and resource context.  The document outlines fair, inclusive, transparent and equitable decision-making processes at the country level on the strategic use of ARV drugs.

The implementation of these guidelines will expand the pool of persons eligible for ART and will require additional investments in the near and medium term.  However, modelling clearly demonstrates that earlier treatment initiation will reduce new infections over the medium to long term as HIV transmission is reduced, and will be a major step forward towards reducing the global burden of HIV.

The full guidelines and accompanying annexes are available at: http://www.who.int/hiv/pub/guidelines/arv2013/download/en/index.html

References

1.     Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 2011, 365:493–505.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy

HIV Update: Antiretroviral therapy

Antiretroviral therapy

By Lucy Stackpool-Moore (IPPF)

A record 10 million people living with HIV now have access to antiretroviral therapy but now is not the time to become complacent

The latest scientific results were presented by the leading thinkers and scientists at the 7^th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) in Kuala Lumpur at the end of June. At this conference, the World Health Organization (WHO) released new international guidelines on the use of antiretroviral (ARV)drugs to inspire more and better access to treatment for people around the world.

The new guidelines call for increased access to ARVs for many people – earlier initiation of treatment for people living with HIV (by increasing the recommended CD4 count to 500 cells/mm3), treatment for life for pregnant mothers living with HIV and any infants born with HIV, and provide operational guidance for programmers and planners to adopt the guidelines. These recommendations are ambitious in a time when pediatric treatment remains unacceptably low and funding to guarantee access to treatment risks being inadequate and unsustainable. Complacency, or so-called ‘AIDS fatigue’, and fears of global financial hardship are all factors that may jeopardize the success of the uptake of the new WHO guidelines. Strong leadership is critical within such a moment in time.

Enhanced access to treatment will not be the panacea for meeting all needs, but it is a good start. It can catalyze a great deal through enhancing comprehensive prevention efforts, ensuring lifesaving and health promoting treatment, and reducing the likelihood of HIV transmission. But even with enhanced access, stigma remains; as do many of the structural determinants that fuel HIV and render people vulnerable to ill-health. New challenges will also emerge in terms of treatment adherence for more people and potential risks of increased drug resistance.

Colleagues from across IPPF have recently responded to a question about the need for an exceptional response to HIV. The responses overwhelmingly affirmed that such a response is still necessary – to consolidate hard-won gains of the last 30 years, to innovate and catalyze strengthening in health systems, to protect human rights of the most marginalized people around the world (who are often also the most vulnerable to HIV), and to continue to tackle wider structural determinants of health. As one colleague said, quite simply, “stigma still remains as a great obstacle in many senses: cultural, and political. People that need treatment, don´t have it yet.”

Visionary leadership for HIV is as critical now as ever before. People matter, and every person’s life is important. Now and for the foreseeable future, HIV is part of life – as is living with HIV – for individuals, families, communities, societies and countries around the world.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy