New Scottish HIV Action Plan

posted: 01/12/2009

Scotland’s HIV Charities have welcomed the launch of the Scottish Government’s HIV Action Plan.
 

A full review of the needs of people living with HIV, the best ways of reducing HIV provide the ground for the Scottish strategy for the next five years. This first Scottish national HIV action plan is intended to give a much needed boost to HIV awareness and prevention.
 

The latest statistics released by Health Protection Scotland show that rates of HIV diagnosis in Scotland remain at record levels. HIV charities support the Action Plan’s closer combination of prevention and treatment interventions to strengthen Scotland’s response to HIV.
 

This integrated approach will help those attending clinics for testing and care to get information and support to protect themselves and their partners. Outreach and awareness raising work with communities will emphasise the benefits of early HIV testing.
 

HIV Scotland’s Roy Kilpatrick said, “This Action Plan recognises the need for HIV prevention at many different levels, along with the imperative that the growing numbers of people on treatment get the very best care, wherever they live and whatever their background. We welcome the recognition within the Plan of the need to work collaboratively across sectors. It is pleasing to see that the Plan deliberately sets ambitious goals for the next five years that involve charities, government, health experts and individuals, in intensifying our efforts and scaling up the work.”
 

David Johnson, Director of Waverley Care, Scotland’s largest HIV charity, described how Waverley Care provided a wide range of support for a wide range of people and needs from children through mothers and fathers to gay men. He said "Practical support and respite are also essential components of care. But at the end of the day, people themselves make the difference, and the HIV Action Plan has much in it that will help organisations like Waverley Care in their work with people living with HIV."
 

Parliament launch

The HIV Action Plan was launched today by Scotland Minister for Public Health, Shona Robison, with a debate in the Scottish Parliament led by Jack McConnell MSP. Health Protection Scotland issued its comprehensive report to link with this launch.
Scottish HIV Action Plan, or available also from this page Scottish HIV Action Plan   
 

HIV figures and comment from Health Protection Scotland

Source HIV Scotland

How-To Guide for African HIV Prevention

posted: 10/11/2009

Sigma Research have just published the 'How-To' guide for HIV prevention among Africans living in the UK, called the "African HIV prevention Handbook: putting The Knowledge, The Will and The Power into practice."

This follows the prevention action plan produced in 2007-08 with the National African HIV Prevention Programme (NAHIP). That described the state of the HIV epidemic among African people living in England and set out the purpose, targets and aims for planning HIV prevention for Africans in this country. The chief goal is to minimise the number of sexual HIV acquisitions and transmissions involving African people living in England.

Sigma worked closely with the NAHIP to produce this ‘How-To’ handbook. It clearly describes the broad range of possible HIV prevention interventions, and clarifies the concepts and the language used to describe various interventions. It describes prevention interventions, their limitations and ways to get the best out of them.
 

Working well together has led to this handbook with clear and purposeful descriptions of existing ongoing and future HIV prevention interventions for African people in England. Sigma tell us they are proud of the partnership behind this and hope that it will support everyone concerned with reducing HIV transmissions.
 

The 'How-To' African HIV Prevention Handbook can be downloaded from Sigma Research here (or order free printed copies)

The African HIV Prevention Action Plan

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