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Africa: AIDS Treatment 2.0

AfricaFocus Bulletin
Jul 15, 2010 (100715)
(Reposted from sources cited below)

Editor's Note

As donor commitment to the fight against AIDS threatens to falter, UNAIDS, the Joint UN Programme on HIV/AIDS, has issued a new report with ambitious proposals and an upbeat perspective on the prospects for advances in both treatment and prevention. Proposing simplified treatment practices under the rubric "Treatment 2.0," the report also cites significant advances in prevention, particularly among African youth, and widespread global awareness of the importance of the pandemic among issues requiring high priority.

This AfricaFocus Bulletin (at http://www.africafocus.org/docs10/hiv1007a.php) contains the UNAIDS press release on its new Outlook report, and excerpts from the report itself on the principles of Treatment 2.0, and the positive example of successful decentralization and simplification of treatment in Malawi.

Another AfricaFocus Bulletin, available on the web today at http://www.africafocus.org/docs10/hiv1007b.php, but not sent out by e-mail, contains results reports from the Global Fund to Fight AIDS, TB, and Malaria, including a summary of limited advances by some African countries in increasing domestic spending on health.

For previous AfricaFocus Bulletins on health issues, see http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note++++++++++++++++++++

Ten million deaths and 1 million new HIV infections could be averted if countries meet HIV treatment targets

UNAIDS Press Release

UNAIDS, the Joint United Nations Programme on HIV/AIDS

http://www.unaids.org/en/default.asp

July 13, 2010

[Excerpts: For full press release and the report, including extensive graphs and figures, visit the UN AIDS website.]

New UNAIDS report shows that young people are leading the prevention revolution, with 15 of the most severely affected countries reporting a 25% drop in HIV prevalence among this key population. New global opinion poll shows that AIDS continues to be of major importance for the public around the world.

Geneva, 13 July 2010 -- The new UNAIDS Outlook report outlines a radically simplified HIV treatment platform called Treatment 2.0 that could decrease the number of AIDS-related deaths drastically and could also greatly reduce the number of new HIV infections. Evidence shows that new HIV infections among young people, in the 15 countries most affected by HIV, are dropping significantly as young people embrace safer sexual behaviours.

Also in the report, a sweeping new UNAIDS and Zogby International public opinion poll shows that nearly 30 years into the AIDS epidemic, region by region, countries continue to rank AIDS high on the list of the most important issues facing the world.

And an economic analysis makes the case for making health a necessity, not a luxury, outlining the critical need for donor countries to sustain AIDS investments and calling on richer developing countries to invest more in HIV and health.

The report was launched in Geneva ahead of the XVIII International AIDS Conference in Vienna. The UNAIDS Executive Director, Mr Michel Sidib‚, stressed that innovation in the AIDS response can save more lives. "For countries to reach their universal access targets and commitments, we must reshape the AIDS response. Through innovation we can bring down costs so investments can reach more people."

According to UNAIDS' estimates there were 33.4 million people living with HIV worldwide at the end of 2008. In the same year there were nearly 2.7 million new HIV infections and 2 million AIDS-related deaths.

Treatment 2.0 saves lives

Treatment 2.0 is a new approach to simplify the way HIV treatment is currently provided and to scale up access to life saving medicines. Using a combination of efforts it could bring down treatment costs, make treatment regimens simpler and smarter, reduce the burden on health systems and improve the quality of life for people living with HIV and their families. Modelling suggests that compared with current treatment approaches, Treatment 2.0 could avert an additional 10 million deaths by 2025.

In addition, the new approach could also reduce new HIV infections by up to 1 million annually if countries provide antiretroviral therapy to all people in need, following revised WHO treatment guidelines. Today, 5 million of the 15 million people in need are accessing these life-saving medicines.

To achieve the full benefits of Treatment 2.0 progress has to be made across five areas:

  • Create a better pill and diagnostics: UNAIDS calls for the innovation of a smarter, better pill that is less toxic and for diagnostics that are easier to use. Monitoring treatment requires complex equipment and specialized laboratory technicians. A simple diagnostic tool could help to reduce the burden on health systems. Such a simplified treatment platform could defray costs and increase people's access to treatment.

  • Treatment as prevention: antiretroviral therapy reduces the level of the virus in the body. Evidence shows that when people living with HIV have lowered their viral load they are less likely to transmit HIV. It is estimated that ensuring everyone in need has access to treatment, according to the current treatment guidelines, could result in up to a one third reduction in new HIV infections annually.

    Optimizing HIV treatment coverage will also result in other health prevention benefits, including much lower rates of tuberculosis and malaria among people living with HIV.

  • Stop cost being an obstacle: despite drastic reductions in drug pricing over the past ten years, the costs of antiretroviral therapy programmes continue to rise. Drugs can be even more affordable--however, potential gains are highest in the area of reducing the non-drug-related costs of providing treatment, such as hospitalization, monitoring treatment, and out-of-pocket expenses. Currently these costs are twice the cost of the drugs themselves. Treatment 2.0 is expected to reduce the cost per AIDS-related death averted by half.

  • Improve uptake of voluntary HIV testing and counselling and linkages to care: when people know their HIV status they can start treatment when their CD4 count is around 350, rather than waiting until they are feeling sick. Starting treatment at the right time increases the efficacy of current treatment regimens and increases life expectancy.

  • Strengthen community mobilization: by involving the community in managing treatment programmes, treatment access and adherence can be improved. Demand creation will also help bring down costs for extensive outreach and help reduce the burden on health care systems.

"Not only could Treatment 2.0 save lives, it has the potential to give us a significant prevention dividend," said Mr Sidibé speaking at the launch of the report.

Young people leading the prevention revolution

A new UNAIDS study shows that young people are leading the HIV prevention revolution. HIV prevalence among young people has declined by more than 25% in 15 of the 25 countries most affected by AIDS. These declines are largely due to falling new HIV infections among young people.

In eight countries--Côte d'Ivoire, Ethiopia, Kenya, Malawi, Namibia, the United Republic of Tanzania, Zambia and Zimbabwe--significant HIV prevalence declines have been accompanied by positive changes in sexual behaviour among young people.

For example, in Kenya there was a 60% decline in HIV prevalence between 2000 and 2005. HIV prevalence dropped from 14.2% to 5.4% in urban areas and from 9.2% to 3.6% in rural areas in the same period. Similarly in Ethiopia there was a 47% reduction in HIV prevalence among pregnant young women in urban areas and a 29% change in rural areas.

Young people in 13 countries, including Cameroon, Ethiopia, and Malawi, are waiting longer before they become sexually active. Young people were also having fewer multiple partners in 13 countries. And condom use by young people during last sex act increased in 13 countries.

There are 5 million young people living with HIV worldwide, making up about 40% of new infections.

The Benchmark survey

...

Overall, respondents put AIDS as the top health-care issue in the world. Furthermore, about half of the respondents are optimistic that the spread of HIV can be stopped by 2015.

...

When asked about how their country was doing against the epidemic, about 41% of respondents said that their country was dealing effectively with the problem. Only one in three people believe the world is responding effectively to AIDS.

...

When it came to HIV treatment, nearly six in ten believe it is the duty of the state to provide for free or subsidized treatment for people living with HIV.

The poll surveyed adults in 25 countries representing all regions with nearly 12,000 respondents.

Investments in HIV must be sustained, efficient and predictable

Investment in HIV is smart and proven. At this turning point, flat-lining or reductions in investments will hurt the AIDS response. In 2010 an estimated US$ 26.8 billion is required to meet country-set targets for universal access to HIV prevention, treatment, care and support.

"The AIDS response needs a stimulus package now. Donors must not turn back on investments at a time when the AIDS response is showing results," said Mr Sidibé "The 0.7% target on international aid and the Abuja target of 15% for health cannot be buried."

UNAIDS recommends that national HIV programmes invest between 0.5% and 3% of government revenue in the AIDS response. In recent years many countries have increased their domestic investments in the AIDS response. For example, the South African Government increased its budget for AIDS by 30% to US$ 1 billion in 2010. However, for the majority of the countries severely affected by AIDS, domestic investments alone, even when raised to optimal levels, will not suffice to meet all their resource needs.

UNAIDS calls on richer developing countries to meet a substantial proportion of their resource needs from domestic sources. Currently, 50% of the global resources requirement for low- and middle-income countries is in 68 countries where the national need is less than 0.5% of their gross national income. These countries have 26% of the people living with HIV and receive 17% of international assistance for AIDS.

According to the report, current investments in HIV can become more efficient, effective and predictable. "We can bring down costs so investments can reach more people," said Mr Sidibé "This means doing things better--knowing what to do, channelling resources in the right direction and not wasting them, bringing down prices and containing costs. We must do more with less."

Contact UNAIDS Geneva | Saya Oka | tel. +41 22 791 1697 | okas@unaids.org


More on the 5 Pillars, from UNAIDS Outlook report

For full report visit http://www.unaids.org/en/default.asp

Pillar 1

Creating a better pill and diagnostics

When treatment for HIV first came around in 1996, it was a tough pill to swallow--literally. It meant on average taking 18 pills a day, of varying shapes and sizes. Some were taken with food, others on an empty stomach, and rigorous monitoring of the time of day the pill was taken was needed in order to mitigate the risk of the virus becoming resistant to the drugs.

But it worked. People called it the Lazarus effect: people near death became healthy again.

Antiretroviral therapy works by suppressing the virus and stopping it from reproducing. If the active component of the drugs is not kept constant in the body, the virus can mutate, continue to multiply, and become resistant to the drug. By adhering to a treatment regimen--for most combinations this means taking the medication at a given time of day, two to three times a day--drug levels are kept even.

The more different types of pills a person takes, the more substances the body has to accustom itself to, the higher the risk of developing side-effects. Many people living with HIV who have been on treatment can testify to the side-effects -- from depression and fever to lipoatrophy (the loosing of fat from certain areas of the body).

Developing resistance to a regimen is a well-founded fear--once a regimen is no longer effective, people living with HIV may have to move to a second-line of treatment.

Access to second-line treatment is still rare in most low- and low-middle income countries due to the high cost of the pills and more complex monitoring systems and supply-chain management.

Improving effectiveness and ease of use, and lowering side-effects and resistance, need to be considered in the development of new treatment options.

Some regimens already exist as fixed-dose combinations, where multiple drugs are in one pill, but options that have fewer side-effects and have less potential for long-term toxicity (dose optimization, mini-mal requirements for laboratory monitoring) and that are more resilient and tolerant to treatment interruptions (to minimize the development of drug resistance) are needed.

In an ideal scenario, having such a pill could do away with the current need for second- and third-line treatments.

At the same time, simpler diagnostic tools and technologies are in short supply. Pregnancy tests can be used at home.

People who have diabetes can check their blood glucose level nearly anywhere. And if a mother is worried that her child has a fever she has many choices on how to check her child's temperature. All of these diagnostics are easy to use, usually without the need for a doctor or a lab.

The same cannot be said currently for checking HIV status or CD4 and viral load testing. While robust rapid tests are more and more used for the first HIV test, monitoring CD4 counts and viral load requires expensive and time-consuming lab-based tests.

Treatment monitoring that is closer to the patient can lead to better treatment results. It can facilitate early detection and treatment of HIV and can ensure appropriate and rapid response to drug resistance, improving outcomes for people on treatment and reducing the development and spread of drug-resistant strains of the virus.

Innovation is needed to develop inexpensive point-of-care diagnostic tools like simple dip-stick tests to measure CD4 cell counts, viral load or tuberculosis infection.

Pillar 2

Treatment as prevention

Since 1991, the world has known that effective antiretroviral therapy can help to prevent HIV transmission. This has been the case for vertical transmission, for example ensuring that pregnant women living with HIV don't pass on the virus during pregnancy or childbirth.

Recently, however, the dramatic impact of treatment on other forms of HIV transmission has become better understood. Evidence clearly shows that successful viral suppression through treatment can substantially reduce the risk of vertical, sexual and blood-borne HIV transmission.

A recent study, supervised by the University of Washington and largely funded by the Bill & Melinda Gates Foundation looked at 3400 heterosexual couples--each with one HIV-positive and one HIV-negative person--from seven countries in sub-Saharan Africa. When the HIV-positive partner was on treatment, the researchers found the HIV transmission rate was 92% lower than among couples where the person living with HIV did not receive treatment.

This study also confirmed that a significant proportion of all HIV transmission happens during the phase when people living with HIV develop increasing immune impairment (which is marked with increasing viral load and decreasing levels of CD4 counts).

Treatment can become part of a combination prevention strategy. Optimizing treatment coverage will also result in other prevention benefits, including lower rates of tuberculosis.

Treating everyone in need of treatment according to current treatment guidelines could result in a one third reduction in new infections globally.

Further research is urgently needed in order to better understand the possibilities and role of antiretroviral therapy in earlier asymptomatic phases of HIV infection.

Pillar 3

Stop cost being an obstacle

Despite drastic reductions in drug pricing over the past ten years, the costs of antiretroviral therapy programmes continue to rise.

The reported proportion of people on second-line regimens remains low. In 2008, a vast majority of adults (98%) and children (97%) surveyed in 43 high-burden countries were receiving first-line antiretroviral therapy regimens.

In low- and middle-income countries, the average annual cost of the most widely used first-line drug treatments was US$143 per person in 2008, a price reduction of 48% since 2004. There was an even greater price reduction in paediatric formulations, from US$ 436 per person per year in 2004 to US$ 105 in 2008. This all helped to contribute to a wider availability of treatment. Second-line regimens continue to be more expensive.

Drugs can be even more affordable--however, potential gains are highest in the area of reducing the non-drug-related costs of providing treatment. Currently these costs significantly outweigh the cost of the drugs themselves.

Cost savings can be found in every step of the process. A better, singe-dose pill with decreased toxicity and that was resistant-proof would have fewer needs for treatment

monitoring. This would lead to a reduced number of interactions with health-care providers--less health-care time spent on monitoring people enrolled on antiretroviral therapy programmes frees up resources to be devoted to other pressing health issues.

A decreased frequency of interaction with health-care providers also lowers out-of-pocket costs, such as transport fees, for the care seeker.

Simplified treatment and diagnostic approaches would allow for the decentralization of services from specialized health systems to primary and community health-care providers, where antiretroviral therapy administration and monitoring moves from doctors to nurses and community health-care workers.

These simplified approaches will also ensure that investments in HIV treatment directly benefit the delivery of other health programmes, as they happen through the same health-care sites and with the same health-care workers. Infrastructure investments and training benefit more efficiently the delivery of broader health services.

Pillar 4

Improve uptake of HIV testing and linkage to care

The uptake of HIV testing and counselling and linkage to care will need to be improved drastically if the promise of treatment and treatment-centred HIV prevention approaches are to be realized.

Globally only about 40% of people living with HIV know their HIV status--the large majority of whom find out they have HIV by developing clinical AIDS, with their immune system already seriously weakened.

Stigma and discrimination remain as the foremost impediment to HIV testing utilization. For many people even seeking out HIV testing can lead to serious, even life-threatening, exposure to violence, legal action and loss of family, employment, and property. And where care, treatment and support services are unavailable, there is little incentive to take an HIV test.

However, progress is being made. South Africa is scheduled to reach 15 million people in two years. In the United Republic of Tanzania, three million people received HIV tests in six months; in Malawi 200 000 people took HIV tests in one week.

Community-based organizations, often led by people living with HIV, provide an important and effective bridge into HIV testing and a link to treatment and prevention services. Peer-based services are often more trusted than government-led services, especially by populations at higher risk, which can be fearful of government-run health-care approaches.

The results of programmes from countries as diverse as Bolivia, Botswana, China, India, the Russian Federation, Rwanda and Uganda all show the positive impact that individual engagement with community-based services has on increased HIV testing rates and increased use of HIV prevention and treatment services, as well as improved treatment adherence and prevention practices and a reduction in stigma.

We need to learn from and scale up successful models of partnership between health service providers and community-

based service providers to assist in stigma reduction and increased utilization of services in particular by populations at higher risk. Many examples exist in countries, including programmes that receive support from the United States President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

Pillar 5

Strengthen community mobilization

Drug users, men who have sex with men, sex workers and poor women often have little reason to trust government-provided health services. Fear of exposure of their HIV status keeps many people from seeking HIV testing and health services.

Community-based approaches to build trust, protect human rights and provide opportunities for socialization directly improve the ability of people to use HIV services and to benefit from antiretroviral therapy and prevent new infections. In fact, much of the success to date in the AIDS response is due to the unprecedented engagement of affected communities as advocates, educators and service providers.

In the late 1980s, TASO (the AIDS Support Organization) developed models for community-based support services in Uganda that were duplicated all over the world.

Grupo Pela Vidda in Brazil successfully helped advocate for full antiretroviral therapy coverage in the country, which led to a 50% drop in AIDS-related deaths in one year.

Work by AIDS activists in the United States of America helped to cut the time its takes to approve new drugs for life-threatening illnesses in half, leading to the early approval and availability of highly active antiretroviral therapy in 1996, saving millions of lives.

...

The Treatment Action Campaign in South Africa successfully confronted a government that failed to address the most destructive HIV epidemic in the world, leading to the development of treatment access programmes throughout the country and an increased commitment to HIV testing and prevention.

Simplified approaches to treatment offer unique opportunities to increase community-based delivery of outreach and support services, with direct positive effects for prevention and for lower-cost treatment.

Decentralizing HIV treatment in Malawi

According to government sources, nearly 200 000 people living with HIV in Malawi were accessing antiretroviral therapy in 2009, up from about 10 000 in 2004. Between 2003 and 2009, the number of sites in Malawi providing antiretroviral therapy increased from nine to 377. A decentralized approach to HIV treatment and care was critical to this national success in antiretroviral therapy scale-up.

Under Malawi's first national antiretroviral therapy guidelines of 2003, only doctors and clinical officers--based primarily at larger health facilities in urban settings--were empowered to start patients on antiretroviral therapy. Medical assistants and nurses could monitor and follow up on a patient's progress, but were not able to prescribe treatment.

With about 85% of the population in Malawi living in rural areas, treatment access became an important issue. "Some people had to travel 100 kilometres to be assessed if they were eligible for antiretroviral therapy," says Professor Anthony Harries, an adviser to the Malawian government's HIV programme from 2003 to 2008. "Though this was a free service, it meant time away from work. Those who did manage to access antiretroviral therapy had great difficulty continuing treatment because of the cost of transport."

Malawi's new antiretroviral therapy scale-up plan (2006-2010) included a number of strategies to bring HIV treatment closer to the primary point of care, where the majority of the population lives. Under the new guidelines, medical assistants and nurses were empowered to initiate antiretroviral therapy--from 2006 and 2008, respectively.

In partnership with the Ministry of Health and district-level medical facilities, many community-based health centres were accredited as antiretroviral therapy delivery clinics. About 88 000 people started antiretroviral therapy in 2009 alone. Of the 377 sites in Malawi in which antiretroviral therapy is now offered, more than 50% are simple health centres.

"Through this decentralized approach, we were able to reach out into the communities, where people otherwise could not access treatment," says Dr Frank Chimbwandira, Director of the HIV/AIDS Department in Malawi's Ministry of Health. "We were also able to improve treatment follow-up, as more people could come back and forth from the health centres to access their medication."


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

AfricaFocus Bulletin can be reached at africafocus@igc.org. Please write to this address to subscribe or unsubscribe to the bulletin, or to suggest material for inclusion. For more information about reposted material, please contact directly the original source mentioned. For a full archive and other resources, see http://www.africafocus.org


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