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Closing the HIV services gap

Dr Gottfried Hirnschall, Director, Department of HIV/AIDS

Commentary
27 November 2014

I remember vividly when I joined the HIV Department in WHO. One of the most incredible health inequities was about to be addressed: WHO and its partners were to set the world’s first target for antiretroviral (ARV) treatment - “3 by 5”. The goal was to provide 3 million people with ARV treatment by 2005.

Dr Gottfried Hirnschall, Director, Department of HIV/AIDS.
WHO

As much as we were all enthusiastic, there were great uncertainties, and, to be quite honest, many, many open questions: would the larger community “buy into this”, will weak health systems cope with increasing demands, and critically - who would pay?

14 by 14

Today, more than 14 million people are taking ARVs – a sure sign that the world is working towards closing the gap in providing access to HIV treatment. The drugs they take have become much cheaper, safer, and simpler (just one pill a day instead of a handful of different tablets). They are able to start taking them earlier, before they get sick. They take those medicines to keep themselves healthy. But also to limit the chance that HIV gets passed on to their partners and their children.

I have just returned from South Africa. South Africa has the world’s largest HIV epidemic, but has now become a shining example of what can be achieved, with drive, commitment, resources, and the willingness to embrace innovations quickly. Today, more than 2.7 million people are taking ARVs; services are available from grass-roots level up; there has recently been a major scale-up of testing, and the country has a concrete plan on the way forward.

“We have come a long way, but do have challenges. Providing greater support to ensure people keep taking their medicines and adhere to treatment is one of them,” Dr Yogan Pillay, the deputy Director-General responsible for HIV, TB and Maternal and Child Health, shared with me last week in Johannesburg. “This is an area where we can do better and must do better, while we continue to enrol many more people on treatment”.

Part of that country plan is to implement WHO’s recommendation for the “strategic use of ARVs” to both prevent and treat HIV – a core element of the Organization’s consolidated ARV guidelines published in June 2013.

Using ARVs strategically

The guidelines emphasize the potential health gains to be made by offering ARVs to people not only to safeguard their own health, but also to prevent new infections. WHO also recommends offering treatment to pregnant women to reduce transmission to their babies, and to sexual partners who do not have the virus. The same guidelines recommend that people start taking medicines far earlier in the course of their disease when their immune system is still strong, below a CD4 cell count threshold of 500.

Since WHO launched the recommendations 18 months ago, 71 countries have adopted the new guidelines. Many countries are increasing domestic financing for treatment scale-up, to complement external funding.

Today, many regard the strategic use of ARVs as the cornerstone for a more ambitious plan to end the AIDS epidemic: If 90% of people know their status, 90% of those receive ARVs, and 90% of those manage to suppress the virus, there is a real chance to come close to “zero” new HIV infections and “zero” deaths by 2030.

The gap

So how far have we come and how much more remains to be done? Although many more people now know their HIV status than when I first joined WHO, about half of all the people in the world who live with HIV still do not know they have the virus. This calls for a concerted effort to offer testing more widely and more focused, and to provide treatment as early as possible.

It will also be critical to ensure that when people start taking ARVs, they keep taking them. It’s not always easy for people to keep motivated to take medicines when they don’t feel ill – and to keep taking them for the rest of their lives. Globally, one in seven new ART patients is “lost to follow up” after one year.

A big challenge now is among people who are particularly affected by HIV – girls and young women in sub-Saharan Africa, migrants and mobile populations in many parts of the world, and other “key populations”, specifically men who have sex with men, transgender populations, sex workers, people who inject drugs, and incarcerated persons, pretty much universally. That’s why WHO released a new set of recommendations at this year’s International AIDS Conference in Melbourne – highlighting the evidence that all the recommendations made in 2013 should be applied to all population groups, and that barriers to accessing these health services need to be removed.

On World AIDS Day 2014, we are issuing an additional set of guidelines to further improve the quality and effectiveness of both HIV prevention and treatment programmes: we recommend countries increase access to ARVs for people who have been exposed to HIV (commonly referred to as post-exposure prophylaxis) – health workers, for example, who might have been exposed to unsafe blood, and people who may have had unprotected sex – to prevent infection. We also suggest ways in which countries can provide better clinical care for people living with HIV and other infections - such as TB or hepatitis.

Closing the gap on HIV treatment will bring enormous benefits in keeping people healthy and alive, and in reducing new infections. But closing the treatment gap alone will not be sufficient to end the AIDS epidemic. A parallel increased prevention effort is required, including condom programming, harm reduction, voluntary medical male circumcision and continued focused on those groups who continue to experience high rates of infection and are not currently reached.

Closing the gaps in access for both HIV prevention and treatment, and achieving the 90-90-90 targets is at the same time an inspiring vision and a massive challenge. We are, in some ways, at a comparable moment to when "3 by 5" was first embraced, except that we are, at least, half-way there. We must not “take our eye off the ball” and let this unique opportunity pass.