Global Treatments Working

posted: 24/11/2009

The death toll from HIV across the world fell by more than 10% over the past five years, latest figures show. The World Health Organization and the Joint UN Programme on HIV/AIDS (UNAids) say that since effective treatments first became available in 1996, some 2.9 million lives have been saved.

As the number of deaths has fallen, the number of people living with HIV has risen slightly - an estimated 33.4 million people worldwide are infected with HIV, up from 33 million in 2007 because of fewer deaths.
 

New infections fall
The latest report also shows there has been a significant drop in the number of new HIV infections. The report suggests that HIV prevention programmes are having a significant impact - new HIV infections have fallen by 17% over the past eight years.
 

In sub-Saharan Africa, the epicentre of the global pandemic, the number of new infections has fallen by around 15% since 2001 - equating to about 400,000 fewer infections in 2008 alone. In the same period, infection rates were down by nearly 25% in East Asia, and by 10% in South and South East Asia. In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the rate of infection has levelled off considerably.
 

UNAids executive director Michel Sidibe said although prevention programmes had helped cut new infections, they were often "off the mark". "If we do a better job of getting resources and programmes to where they will make most impact, quicker progress can be made and more lives saved," he said.

Prioritise Gay Men in UK

Deborah Jack, chief executive of National AIDS Trust, said: “The downward trend in new infections is a testament to the work of the international HIV community. It’s the result of the roll-out of treatment and increased investment in prevention initiatives.

"However today’s report shows there are gaps in prevention programmes that meet the needs of key groups, such as over 25s and gay men. We need to get smarter about HIV prevention and also sustain efforts to find new tools such as microbicides and a vaccine, if we are to seriously reduce new infections.

"Worryingly, the global decrease in new infections is not being seen in the UK. Here new diagnoses have trebled in the past ten years. HIV diagnoses among men who have sex with men in the UK rose by 74 per cent between 2000 and 2007. The UK needs to re-prioritise HIV prevention among gay men, otherwise we risk falling further behind.”
 

UNAIDS global HIV epidemic update 2009

Source

HIV and supporting women’s health

posted: 10/11/2009

The first study of women's health around the world by the World Health Organisation (WHO) says HIV is the top cause of death and disease among women between the ages of 15 and 44. While women provide the bulk of HIV care and support across the world, women’s own health needs, including for HIV, are neglected. The report from WHO is called Women and health: today's evidence tomorrow's agenda.

Women’s vulnerability through unsafe sex is the leading risk factor in developing countries for women of childbearing age, alongside not being able to obtain contraceptives and iron deficiency, the WHO said. Throughout the world, one in five deaths among women in this age group is linked to unsafe sex.
"Women who do not know how to protect themselves from such infections, or who are unable to do so, face increased risks of death or illness," WHO say in their 91-page report. "So do those who cannot protect themselves from unwanted pregnancy or control their fertility because of lack of access to contraception."
 

Women provide most health care, but rarely receive the care they need
Worldwide, women provide the bulk of health care - whether in the home, the community or the health system, yet health care continues to fail to address the specific needs and challenges of women throughout their lives.
 

Up to 80% of all health care and 90% of care for HIV-related illness is provided in the home - almost always by women. Yet more often than not, they go unsupported, unrecognized and unpaid in this essential role.
 

When it comes to meeting women's health care needs, some services, such as care during pregnancy, are more likely to be in place than others such as mental health, sexual violence and screening and treatment for cervical cancer.
 

However, in many countries, sexual and reproductive health services tend to focus exclusively on married women and ignore the needs of unmarried women and adolescents. Few services cater for other marginalized groups of women such as sex workers, intravenous drug users, ethnic minorities and rural women.
 

Women's fundamental right to health

"It's time to pay girls and women back, to make sure that they get the care and support they need to enjoy a fundamental human right at every moment of their lives, that is their right to health," said Dr Chan.
 

The report highlights the unequal health treatment women and female children face from childbirth through infancy and adolescence into maturity and old age.
 

Women stronger
WHO chief Dr. Margaret Chan noted that women enjoy a biological advantage because they tend to live six to eight years longer than men. But in many parts of the world they suffer serious disadvantages because of poverty, poorer access to health care and cultural norms that put a priority on the well-being of men, she said.
 

Women's health suffers as second-class citizens

Lack of access to education, decision-making positions and income may limit women's ability to protect their own health and that of their families. Though major differences exist in women's health across regions, countries and socio-economic class, women and girls face similar challenges, in particular discrimination, violence and poverty, which increase their risk of ill-health.
 

For example, with HIV women face not just a higher risk of getting HIV than heterosexual men because of the biological difference between women and men, but this is worsened by cultures that limit women’s knowledge about HIV and their ability to negotiate safer sex.
 

"We will not see significant progress as long as women are regarded as second-class citizens in so many parts of the world," Dr Chan said. "In so many societies, men exercise political, social and economic control. The health sector has to be concerned. These unequal power relations translate into unequal access to health care and unequal control over health resources," she added.
 

Wide policy changes and action needed
The report seeks to identify key areas for reform, both within and outside the health sector. These include identifying mechanisms to build strong leadership with the full participation of women's organizations, strengthening health systems to better meet women's needs throughout their lives, leveraging changes in public policy to address how social and economic determinants of health adversely impact women, and building a knowledge base that would allow a better tracking of progress.
 

Strategies to improve women's health must also take full account of gender inequality and address the specific socioeconomic and cultural barriers that prevent women from protecting and improving their health, the report points out.
 

Source and the report
WHO press release
Report - Women and health: today's evidence tomorrow's agenda
 

5M Still Waiting for Treatment

posted: 01/10/2009

Although four million people are now receiving antiretroviral treatment in low and middle-income countries, another five million adults and children lack access to treatment, according to figures released today by United Nations agencies.

The report Towards universal access: scaling up priority HIV/AIDS interventions in the health sector is published by the World Health Organization, UNAIDS and UNICEF, and is the third annual review of international progress towards the goal of universal access to treatment and prevention by 2010.

Although more than a million people are estimated to have been enrolled into treatment programmes during 2008 alone, the biggest annual increase since treatment scale-up began, only 42% of those in need of treatment in low and middle-income countries are currently being reached.

Mothers and babies

The report also reveals major gaps in two priority areas, the prevention of mother to child transmission and treatment of children.

The report estimates that 21% of pregnant women received an HIV test in 2008, and 45% received drugs to prevent mother to child transmission, of whom around one-third received only single-dose nevirapine, the least effective form of preventive treatment. Only one-third of those who tested positive were assessed for eligibility for antiretroviral treatment for their own health.

Although 38% of children with HIV in low- and middle-income countries in need of treatment received it, infant diagnosis continues to lag behind. In 41 reporting low- and middle-income countries only 15% of children born to HIV-infected mothers were tested for HIV within the first two months of life.

Background to universal access
In 2001 the convening of The United Nations Special Session on HIV/AIDS marked an historic beginning. For the first time a global set of targets was agreed in response to the crisis. In 2006 at the second United Nations General Assembly High Level Meeting on HIV/AIDS, countries agreed to work towards the goal of “universal access to comprehensive prevention programmes, treatment, care and support” by 2010. The G8 Final declaration in L’Aquila, Italy in July 2009 claimed “We will implement further efforts towards universal access to HIV/AIDS prevention, treatment, care and support by 2010”

WHO, UNICEF and UNAIDS in collaboration with other international monitoring and reporting mechanisms have been monitoring progress, nationally, regionally and globally, of the health sector’s response to HIV. The report presented today is the third in a series of annual progress reports towards universal access that includes HIV services for women and children.

Reports standardised

WHO together with UNICEF developed a joint reporting tool to request information from national programmes to collect data on the scale-up of health sector interventions in response to HIV. The goal of this process is to facilitate the collection of a standardised set of information.

By the end of 2008 between 3.7 and 4.3 million people were on antiretroviral treatment including an estimated 275,700 children (38% of those in need) under the age of 15 years.

Progress varies by country and region. In sub-Saharan Africa, for example, where two-thirds of all global infections occur, an estimated 2.9 million people were on treatment by the end of 2008, with an approximate increase of 800,000 people during 2008.

edited from aidsmap

Reference
WHO, UNICEF, UNAIDS. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. September 2009.

Testing and Treatment for All?

posted: 28/11/2008

Universal testing and treatment could reduce new HIV infections in southern Africa by 95% in 10 years - that is the astonishing prediction in a new World Health Organisation (WHO) discussion paper. 

Universal HIV testing and immediate antiretroviral therapy for everyone diagnosed with HIV in a country with very high HIV prevalence could reduce new infections from 20 per thousand to 1 per thousand within ten years (a 95% reduction), according to findings from a mathematical modelling exercise carried out by the World Health Organization, published in The Lancet.

annual tests and immediate life-long treatment
The findings suggest that HIV transmission could be virtually eliminated by 2020 in countries with high levels of HIV prevalence, such as South Africa, if it were possible to persuade everyone in the community to test for HIV infection once a year and then provide antiretroviral therapy to all who test HIV-positive.

not a real plan
These are not real proposals or part of any WHO plan. They are simply a What If? exercise to help debate possible future strategies.

Currently only around 20% of people with HIV in sub-Saharan Africa know their HIV status, and antiretroviral therapy in most countries is available only to those with symptoms of HIV disease or severe immuno-suppression (a CD4 count below 200 cells/mm3).

Expanding treatment to all those who need it under current guidelines will be a substantial undertaking. Three million people are currently receiving antiretroviral therapy worldwide, but an estimated 6.7 million are still in need of treatment and a further 2.7 million became infected during 2007, according to WHO’s 2008 report on progress towards universal HIV treatment access.

Expanding treatment and testing to reach everyone with HIV, particularly in southern Africa, would be a massive undertaking that would require vastly greater human resources than currently available for health care.

Dr Kevin de Cock, WHO’s HIV department director says that universal testing and treatment regardless of immune system status could not become an official WHO recommendation without further research into the feasibility, safety, acceptability, impact and cost-effectiveness of the approach, as well as extensive consultation.

Nevertheless the findings are likely to stoke interest in expanding access to antiretroviral therapy in order to limit the long-term impact of the HIV epidemic in the most severely affected countries, those in the southern African region where HIV prevalence in the adult population ranges from 15 to 35%.

Treating everyone with HIV infection in order to reduce the number of new HIV infections has been advocated previously by Professor Julio Montaner of the University of British Columbia in Canada. The professor is President of the International AIDS Society. Their own mathematical modelling was published in 2006, and it projected that new HIV cases would decline from 7 per thousand to 0.1 per thousand over 50 years if universal testing and treatment were implemented.

The introduction of door-to-door HIV testing and counselling and antiretroviral therapy for all who qualified under Ugandan treatment guidelines reduced new cases of HIV infection by around 90% over a three-year follow-up period, according to findings from a US Centers for Disease Control study carried out in rural Uganda over the past five years.

No universal testing and treatment anywhere yet
So far no country or region in the world has adopted a strategy of universal testing and treatment. Current treatment guidelines in the United States and Europe recommend treatment for everyone with a CD4 cell count below 350 cells/mm3, although there is some evidence that starting treatment at a CD4 count below 500 reduces the risk of serious non-AIDS-defining illnesses when compared to starting treatment at a CD4 count below 350 cells/mm3.

Canadian treatment plan could cut infections by 2/3 by 2030
Encouraging treatment uptake in order to reduce HIV transmission is an explicit public health goal in only one region of the world at present, the Canadian province of British Columbia, where Professor Montaner’s research group has persuaded the provincial government to adopt a more aggressive approach towards identifying everyone currently eligible for treatment at a CD4 count of 350 cells/mm3 or below. The group’s modelling suggests this policy could avert more than two-thirds of projected infections in the province between 2008 and 2030.

S African calculation for WHO
The WHO model used South Africa as an example, taking data on infection rates and disease progression to model the effects of expanding knowledge of HIV status and a growing uptake of antiretroviral treatment.

The model assumed that with a baseline HIV prevalence of 16%, a 99% decline in infectiousness when individuals started treatment, and 90% coverage of treatment in the HIV-infected population by 2016, 104,000 deaths would be averted in 2015 alone when compared to starting treatment at a CD4 cell count of 350 cells/mm3 (in itself an optimistic threshold). The model assumed an annual treatment cost (including drugs, monitoring and patient management) of $727 a year for first-line treatment and $3290 for second-line treatment, with antiretroviral drugs accounting for 30% of the cost.

infections plummet as treatment rises
The model showed that HIV transmission would decline very steeply as HIV treatment coverage expanded, falling from around 15 new infections per thousand adult and adolescent inhabitants today to 1 per thousand by 2016.

costs 3 times higher at the start but soon the benefits appear

Although the universal treatment strategy would cost three times more than treating everyone with a CD4 cell count below 350 cells/mm3 in 2015 ($3.4 billion a year), the yearly cost would begin to fall after this point, and by 2030 the approach would become less expensive than treating only those with CD4 counts below 350 cells/mm3 (approximately $1.8 billion).

individuals rights set aside for wider benefit

Professor Geoffrey Garnett and Rebecca Baggaley of London’s Imperial College, both HIV epidemiologist, said in an accompanying commentary: “[The] suggested strategy would be extremely radical, with medical intervention for public health benefits rather than individual patient’s benefits. Because screening and treatment would be for the public good, resources would have to come from the public purse. The suggested strategy would reflect public health at its best and its worst”

over-testing, over-treatment, side-effects, and loss of personal autonomy
“At its best the strategy would prevent morbidity and mortality for the population, both through better treatment of the individual and reduced spread of HIV," they continue. At its worst, the strategy will involve over-testing, over-treatment, side-effects, resistance and potentially reduced autonomy of the individual in their choices of care;

what next? forced testing and treatment?
It is easy to see how enforced testing and treatment for the good of society would follow from such an argument. Partial success would lead to infection becoming concentrated in those with a high risk, with an increased danger of stigma and coercion.

universal testing and treatment could worsen stigma
The history of the control of sexually transmitted infections documents several examples of compulsory screening and treatment of stigmatised populations, and there is a danger of a well-meaning paternalistic medical model following such a route.

2008 Mexico Conference support
There was strong advocacy for achieving universal treatment coverage on prevention grounds at this year’s International AIDS Conference in Mexico City. Professor Julio Montaner, who is also President of the International AIDS Society, said: We believe there is now enough evidence to say to policymakers that if you roll out HIV treatment with 100% coverage, you will see a reduction in HIV transmission.

WHO says it needs to know more about the following questions in order to determine whether its modelling is accurate:
• What is the acceptability of universal HIV testing and will it be genuinely universal?
• How infectious are people receiving antiretroviral therapy, especially in settings where the rate of sexually transmitted infections is high?
• How well do people adhere to antiretroviral therapy in the long-term?
• What are the long-term failure rates for antiretroviral therapy and what are the subsequent resistance patterns? To what extent will these restrict the response to second-line therapy?
• What are the effects of universal testing and antiretroviral availability on sexual behaviour?

The feasibility of the approach also needs to be tested in a real health system, in order to determine the level of health personnel and health system strengthening required, as well as the effects of the approach on other public health goals. The UK’s NHS couldn’t make such a change quickly and would need many more trained staff and space for universal testing and treatment. It would be far harder to implement even in South Africa, the most prosperous country in Africa.

More information is also needed about the trade-off between earlier treatment and drug toxicity. In many developing countries first-line treatment includes drugs with quite high rates of toxicity, including d4T (stavudine) and AZT (zidovudine). Using these drugs, which are much cheaper than the better tolerated first-line regimens now used in Europe and North America, could have significant long-term disadvantages if they cause a high rate of serious side-effects in otherwise healthy people.

Source with full references

related article in The Economist