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Thursday, July 26, 2012

Expanding HIV testing and treatment globally


At the Thursday morning plenary of AIDS 2012 in Washington DC, Gottfried Hirnschall MD, Director of HIV at World Health Organization, argued for the expansion of HIV diagnosis and treatment world-wide.

Background:

At present, just over half the people requiring antiretroviral treatment (ART) globally can currently access it. For every person who starts ART, another two become infected, so there is a major disconnect between HIV prevention, incidence of new infection and treatment.

The World Health Organization (WHO) contends that applying new knowledge about the clinical and preventive benefits of antiretroviral treatment (ART) is critical to addressing this gap. For example, providing ART to HIV-positive partners in sero-discordant couples, HIV-positive pregnant women and key populations, will keep infected people well and to reduce transmission.

Providing ART to more people earlier in the course of infection will inevitably increase the numbers of people eligible for ART. Current approaches to scale up access to ART will therefore not be sufficient. Forward-looking policies, innovative approaches to service delivery and further investments in the systems needed to support larger numbers of people on ART will be required.

The Numbers:

Currently, there are 8 million people worldwide receiving ART. The WHO goal is 15 million people taking ART by 2015. Dr. Hirnschall says this is an achievable target when we look at the trajectory of numbers of people on ART since 2002.

The resource implications of current policy shifts to expand access to ART cannot be ignored. Modelling work done to date shows that frontloading of investments in ART in the next five years should lead to cost-savings in the medium- to long-term, as well as sizable societal benefits in terms of infections averted and productivity maintained.

Overall, 57% of adults with CD4 counts <350 cells are receiving ART with the biggest gaps in Eastern Europe and Central Asia (~25%). Overall, only 28% of children with CD4 <350 are receiving ART - so there are major challenges to scaling up.

The other disconnect is low to middle income countries is that, although people on ART has increased, mortality and new HIV infections have shown modest declines - presumably due to adherence issues and starting ART later than optimal.

Conclusions:

Accordingly, WHO has issued its new ART-related guidance (2012) that highlights both (1) Treatment as Prevention and (2) Pre-exposure Prophylaxis for sero-discordant couples and MSM. Obviously, earlier ART is built into (1) Treatment as Prevention.

WHO is also looking toward unifying their guidance in 2013 to overcome barriers such as major variations in ART eligibility thresholds among countries. Sadly, mean CD4 count at ART initiation in low and middle income countries is still below 200.

To summarize the issues and needs -
•Global progress on scale-up of ART has been extraordinary. Countries show the way! 15 million can be reached
•Further scale-up must address disparities and inequities (countries, key populations)
•With new evidence and new policies, the number of persons eligible for ART will increase
•Countries face strategic choices and are already taking advantage of new opportunities (early ART, TasP, PrEP)

Reference:
Hirnschall G. Expanding HIV testing and the use of ARVs for treatment and prevention. THPL0104. http://pag.aids2012.org/flash.aspx?pid=1547


Source: Reporting for the PRN News: Bill Valenti, MD