Any attempt to expand treatment still faces a number of
bottlenecks, many of which are attributable to a lack of trained staff and a
lack of health systems information. All of these are likely to be well known to
readers of HATIP.
Performance at each of these stages needs to be maximised in
order to achieve anything approaching the 96% reduction in transmission rates
seen in HPTN 052.
- Improving rates of diagnosis without
coercion: Even though awareness of the benefits of antiretroviral
therapy is spreading in the worst-affected countries, reluctance to test
for HIV is still widespread, and the median CD4 count at the time of
diagnosis remains very low. Improving the acceptability of testing for
HIV, dispelling the stigma associated with HIV and informing people about
the effectiveness of treatment will be critical steps in scaling up
treatment so that it has an impact on new infections as well as illness
and death. Models of community-wide testing that respect the rights of
people not to test, and which ensure confidentiality, will be critical in
achieving widespread uptake of testing.
- Linkage to care and retaining people
in care prior to ART: referral from testing facilities and retention
in care of untreated people continue to pose challenges for many
treatment programmes. In some settings barriers such as co-payments for treatment and
transport to clinics will pose problems.
- Capacity to initiate patients onto
treatment: Even if rates of testing and diagnosis are high, this will
have little or no effect in prevention terms unless people who are
eligible begin treatment promptly. This is critically dependent on the
capacity of the health system to start patients on treatment, and is
likely to require task-shifting in order to expand the number of health
care workers who can initiate and / or monitor treatment. Efforts to
delegate prescribing or monitoring of antiretroviral treatment to nurses
and other non-physician health care staff are at variable stages across
sub-Saharan Africa, and will need much
greater emphasis if health systems are to reach ambitious targets for
treatment enrolment.
- Proportion of eligible persons on
therapy: a survey of
cohorts in 8 PEPFAR focus countries in sub-Saharan Africa
showed that between 2005 and 2008 the median CD4 count at treatment
initiation was 135 cells/mm3, indicating that any preventive
benefit of ART would occur only after a long period of undiagnosed
infection had elapsed. The proportion of persons on treatment will
obviously depend on the CD4 threshold for starting treatment, and who is
eligible to start treatment at what CD4 level.
- Proportion of patients retained in
care: Some treatment programmes report high rates of loss to follow-up
in patients who have already started treatment. In some cases patients are
lost because they started treatment too late to save their lives, but in
many cases features
of the treatment programme are to blame.
- Proportion failing therapy:
Although treatment failure and the risk of drug resistance has been held
up as the great flaw in the `treatment as prevention` model, treatment
failure in people who remain engaged in care is likely to be less of a
problem than loss to follow-up. Nevertheless, a better understanding of which
adherence interventions are most effective, and in which settings,
will be critical in limiting rates of treatment failure. Earlier treatment
carries with it the risk that if people fail treatment, they will require
more costly second or third-line regimens. Early treatment without strong
adherence support programmes and follow-up mechanisms poses the risk of
earlier treatment failure and correspondingly greater costs in the future.
For all these reasons UNAIDS last year launched a new
concept for thinking about treatment scale-up and the role of treatment as a
prevention tool – Treatment 2.0. This has five components, or `pillars`:
- Creating a better pill and diagnostics: a fixed
dose combination that has a low risk of toxicity, low monitoring requirements
and a low risk of resistance would aid expansion of treatment, as would
diagnostics that could be used anywhere to reduce the burden on health
systems.
- Treatment as prevention as part of a combination
prevention strategy.
- Stop cost being an obstacle by driving down the
cost of treatment and monitoring
- Improve uptake of HIV testing and linkage to
care
- Strengthen community mobilisation in order to
improve the engagement in care of populations at high risk of HIV
infection.
Treatment 2.0 provides an important aspirational goal for
advocates, scientists, donors and policymakers, but the more immediate
questions of how to address the bottlenecks that keep people off treatment and
untested need to be resolved.
In a report to the South African parliament this week,
Health Minister Aaron Motsoaledi showed that addressing the bottlenecks is,
first of all, a matter of political will.
Although things are far from perfect in South Africa,
the country has made dramatic progress in the past year towards scaling up
treatment. As a result of a national campaign that has begun to treat the
epidemics of HIV and TB as the country’s number one health problem after years
of political denial and bureaucratic torpor, South Africa has made dramatic
progress in less than a year.
.
SOUTH AFRICA'S PROGRESS TOWARDS UNIVERSAL ACCESS
|
Before June 2010
|
February 2011
|
Target
|
Numbers tested
|
2 million tests annually
|
11.9 million since June 2010
|
Further expansion of testing at village level, from June
2011
|
Health centres accredited to provide ART
|
490
|
2205
|
All 4000 health outlets by Dec 2011
|
Nurses accredited to prescribe ART
|
250
|
2000
|
4000 by Dec 2011
|
People receiving ART
|
923,000
|
1.4 million
|
3 million by 2015 |
For treatment to have
any impact as a prevention method, this is the minimum level of political
commitment and organisational response that will be necessary to achieve high
levels of diagnosis and treatment coverage.
A more comprehensive approach that aims to test and treat an
even larger proportion of the population will be tested in a number of field
implementation trials now being planned, with the intention of evaluating the
impact of early and widespread treatment on new infections, behaviour and
HIV-related morbidity and mortality. The studies will also evaluate the
cost-effectiveness of offering wider treatment, and the acceptability of
offering the HIV test on a universal basis.
These include studies in Uganda
and KwaZulu-Natal,
together with studies that embed antiretroviral therapy within more
comprehensive packages of `combination prevention`. (See list here).
One challenge for future studies will be defining the
components of a package of combination prevention. Contrary to the assumptions
of many policymakers and donors, we still have remarkably little idea of the
effectiveness of non-biomedical prevention measures in varying settings, or of
how to tailor packages of combination prevention to local epidemic settings.
To take just one example, what should be the balance between
investment in biomedical approaches such as circumcision and structural
approaches such as empowering women and girls, and does this vary according to
HIV prevalence? Although circumcision may result in a rapid reduction in risk
of infection for men because it is a one-off procedure, it will not reduce the
risk of infection for women and girls until it has delivered a long-term
reduction in HIV prevalence for men.
Conversely, although economic empowerment for women and
girls might reduce vulnerability to HIV infection by a variety of mechanisms,
this is likely to be a long-run approach that cannot deliver rapid reductions
in new infections.
Understanding how to strike this balance is part of the very
complex research agenda that we face in learning how to develop combination prevention,
and requires attention not just to the local epidemic – what UNAIDS describes
as `know your epidemic` - but also attention to the local context, which means
everything from understanding what influences people to change their behaviour,
to the ways in which gender roles are understood and talked about in a specific
society.
Another important research issue is understanding how
scaled-up community-based campaigns to offer counselling and testing for HIV
can be integrated with activities that improve TB case-finding across the whole
community, expand the provision of insecticide-treated bednets and effective
treatment for malaria, and improve the diagnosis and treatment of other common infections
and diseases. The community mobilisation necessary for treatment as prevention
to succeed also offers huge opportunities for other health gains to be
achieved. We hope to look in more detail at some examples of these approaches
later in the year.