Tuesday, November 17, 2015

Are the ambitious UNAIDS 90-90-90 targets for 2020 realistic and achievable, considering the end goal of ending the AIDS epidemic by 2030?

By Alan Brand - 18 August 2015

Ending the AIDS epidemic is more than a historic obligation to the 39 million people who have died of the disease. It also represents a momentous opportunity to lay the foundation for a healthier, more just and equitable world for future generations. Ending the AIDS epidemic will inspire broader global health and development efforts, demonstrating what can be achieved through global solidarity, evidence-based action and multi-sectoral partnerships.

Although many strategies will be needed to close the book on the AIDS epidemic, one thing is certain. It will be impossible to end the epidemic without bringing HIV treatment to all who need it.

As the world contemplates the way forward following the 2015 deadline for the targets and commitments in the 2011 Political Declaration on HIV and AIDS, a final target is needed to drive progress towards the concluding chapter of the AIDS epidemic, promote accountability and unite diverse stakeholders in a common effort. Whereas previous AIDS targets sought to achieve incremental progress in the response, the aim in the post-2015 era is nothing less than the end of the AIDS epidemic by 2030.

In December 2013, the UNAIDS Programme Coordinating Board called on UNAIDS to support country- and region-led efforts to establish new targets for HIV treatment scale-up beyond 2015. In response, stakeholder consultations on new targets have been held in all regions of the world. At the global level, stakeholders assembled in a variety of thematic consultations focused on civil society, laboratory medicine, paediatric HIV treatment, adolescents and other key issues.

Powerful momentum is now building towards a new narrative on HIV treatment and a new, final, ambitious, but achievable target:
  • ·        By 2020, 90% of all people living with HIV will know their HIV status.
  • ·  By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • ·        By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

A personal researched perspective on the 90-90-90 UNAIDS targets.

The Benefits of Knowing Your Status
Knowing ones HIV status is no longer a death sentence and as such like many other health conditions testing and screening is the first step to living a healthy life. Knowing your status is empowering oneself  through the gaining of knowledge while engaging with medical practitioners who specialise in HIV treatment and care so that regular monitoring of the effects of the HI virus on one’s immune system will ensure that you can initiate treatment at the most effective time. It also ensures that one has the ability to find psychological support through support networks and support groups and hence one is fully able to take responsibility for one’s life. Not knowing ones status denies one the ability to make these important choices and is simply foolishness. Some of the benefits of knowing your status include:
  •  Knowing your HIV status will help you to reduce the risk of transmitting the virus to others
  • Knowing your HIV status can alleviate the stress and anxiety of thinking that you may be infected but not knowing your actual HIV status.
  • If you test negative for HIV, you can make decisions and take steps that will help you remain HIV negative.
  • If you test positive for HIV, you can seek medical treatment earlier. Early medical treatment can slow the progress of HIV and delay the onset of AIDS. Pregnant women who test positive for HIV can take action to prevent their baby from becoming infected with HIV

Point-of-care Testing
HIV-related point-of-care testing (POCT) technologies have become widely available, and they serve as a catalyst to attaining the UNAIDS-led 90-90-90 HIV treatment targets by improving access to diagnostics in resource-limited countries. The treatment targets aim to accomplish specific goals by 2020 – the first 90-target being that 90% of people living with HIV know their HIV status. Increasing access and maintaining the high-quality of POCT is essential to better patient outcomes and achieving an AIDS-free generation.

In its continued efforts to improve the quality of POCT, the African Society for Laboratory Medicine (ASLM) recently partnered with the World Health Organization (SEARO and WPRO regional offices), PEPFAR, the US Centres for Disease Control and Prevention (CDC), and other global partners, to organise a regional consultation in Phnom Penh, Cambodia, aimed at improving the quality of HIV and syphilis POCT.

A new 'Phnom Penh Statement' gives momentum to the global conversation aimed at improving access and increasing the quality of HIV testing. The Statement endorses the UNAIDS 90-90-90 HIV treatment targets and captures the principle of the rapid test quality improvement initiatives under way in Africa.

The benefits of early and sustained antiretroviral therapy
Viral suppression is defined as, literally, suppressing or reducing the function and replication of a virus. When discussing antiretroviral therapy for HIV, a regimen is considered to be highly successful if it reduces a person's viral load to undetectable levels. The term "viral load" refers to the number of copies of HIV per mL of blood, i.e. the amount of virus in the blood.

In general, people with HIV need to use a combined antiretroviral therapy (cART - also known as highly active antiretroviral therapy or HAART) to achieve long term viral suppression - where the level of circulating virus in the blood remain quite low or undetectable.

Benefits: - Prevention of transmission:
Antiretroviral therapy (ART) for HIV infection provides lasting protection against the sexual transmission of the virus from infected men and women to their HIV-uninfected sexual partners, investigators from the HIV Prevention Trials Network (HPTN) have reported at the 8th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver, Canada in July 2015.

Benefits: - Improved health for the HIV infected individual:
People, who start antiretroviral therapy (ART) immediately after HIV diagnosis, while their CD4 cell count is still high, rather than waiting until it falls below 350 cells/mm3 have a significantly lower risk of illness and death, according to long-awaited findings from the START trial. The final study results were presented on Monday at the Eighth International AIDS Society Conference (IAS 2015) in Vancouver, Canada, and published simultaneously in the July 20 advance edition of the New England Journal of Medicine.

These findings suggest that HIV causes persistent immune system damage soon after infection, and "clearly indicate that ART should be provided for everyone regardless of CD4 count,"

It is well known that starting ART before CD4 cell counts fall to low levels dramatically reduces the frequency of opportunistic illness and improves survival. A growing body of evidence shows that earlier treatment is associated with decreased disease progression and death, as well as minimising the risk of onward transmission of HIV.

Viral suppression a key to the success of the UNAIDS targets?
To be successful, HIV test-and-treat programs in South Africa need to focus more on getting patients to return for ongoing treatment. Fewer than half of patients who tested HIV-positive at a Johannesburg, South Africa, clinic returned to complete eligibility testing for antiretroviral therapy (ART), according to a new study. The study, published in the journal PLOS ONE, tracked 380 patients who had tested positive for HIV. Researchers found no evidence that 142 of them returned for a blood draw—a CD4 count measuring levels of infection-fighting white-blood cells—that would determine eligibility for ART treatment. Of the remaining 238, only about 39 percent completed eligibility testing for ART within three months.

Of those who had blood tests showing they were eligible for ART treatment, 88 percent initiated ART within six months. Among the 185 patients in that ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81 percent were retained in care through two years of treatment. About 9 percent of the patients who either never had a blood draw or never returned to the clinic were known to have died.

Factors contributing to dropping out from and returning to HIV treatment
Dropping out was associated with drug/alcohol use, unstable housing/homelessness, psychiatric disorders, incarceration, problems with HIV medications, inability to accept the diagnosis, relocation, stigma, problems with the clinic, and forgetfulness.

Returning to obtain assistance and treatment was associated with health concerns, substance abuse treatment/recovery, stable housing, and incarceration/release, positive feelings about the clinic, spirituality, and assistance from family/relocation.

Patients aged between 15 and 24 years are significantly more likely to drop out of HIV care compared to individuals in other age groups. The research was conducted in four sub-Saharan African countries and involved patients newly entered HIV care or initiating antiretroviral therapy (ART) between 2005 and 2010. Patients in the 15- to 24-years age group were significantly more likely to be lost to follow-up compared to both younger and older age groups.

This study provides important insights on program outcomes previously not sufficiently described. In addition to confirming attrition 1 year after starting ART the study found that youth were substantially more likely than young adolescents and older adults to die or be lost to follow-up before initiating ART.

These findings suggest that test-and-treat programs must focus on retention, particularly in the pre-ART period, in order to reduce morbidity, mortality, and transmission.

The tools and strategies now exist to end the AIDS epidemic by 2030. However, getting there requires unprecedented action now to scale up early antiretroviral therapy, as delay will merely allow the epidemic to continue to outpace the response. While new thinking and new ways of operating will be needed to achieve these ambitious targets, the partnerships that have enabled the AIDS response to make history provide a firm foundation on which to embark on a worldwide effort to end the AIDS epidemic by 2030. Hence the 90-90-90 UNAIDS targets for 2020 are key to achieving this goal and although ambitious can be achieved. 

First reactions – (On being Diagnosed HIV+) – Living positively with HIV.

By Alan Brand, 01 December 2015 (Article for World AIDS Day 2015)

People react in many different ways when they hear that they have HIV. You might carry on as if nothing has happened, you may search out lots of information, or you might find it difficult to accept the news.

You may blame yourself. But HIV does not infect people because they ‘deserve it’ – having HIV does not mean you are a wicked, immoral or stupid person.

Most people get HIV from a sexual partner. You might not have known about HIV at the time, or not thought you were at risk, or you might have decided not to worry about it for once. All these are very normal, human things to do.

You may blame someone else. If you think you know who passed HIV on to you, you may understandably feel angry with them.

But they may not realise that they have HIV. Very often, HIV is passed on by people who have only had it for a few months themselves, usually without knowing.

Or they may have known and not told you. Perhaps things would be better if they had done. But many people are afraid of telling others, because they feel ashamed, or are worried about being rejected. It’s not easy to tell. We’ll look at how to tell other people later. 

Keeping an eye on your health
You can’t tell from someone’s physical appearance, if they have HIV or not. And you can’t always know how good their health is. But blood tests can show how HIV is affecting your health. Whether or not you are taking treatment, it’s important to have some tests done regularly.

One important test is called a CD4 count and is a measure of the strength of your immune system. A low CD4 count means that HIV is damaging your immune system. A higher CD4 count shows that your immune system is stronger. Another test is called a viral load. It’s a measure of the amount of HIV in a sample of blood. If you are taking treatment, the viral load test shows how well your treatment is working – the lower it is the better.

Have these tests done every 4 to 5 months. They will help you and your doctor make decisions about your health and treatment.

Quick guide to test results:

CD4 counts (An important monitor to determine when to embark on treatment as it measures the strength of your immune health)
·         Between 500 and 1200 = usual for people who do not have HIV
·         Above 350 = HIV treatment is not usually recommended
·         Below 350 = HIV treatment is recommended
·         Below 200 = There is a higher risk of illness and infections, so HIV treatment is recommended

Your doctor may give your CD4 results as a percentage
·         Above 29% = similar to CD4 count of above 500
·         Below 14% = similar to a CD4 count of below 200

Viral Load (An important monitor to determine how well your ARV treatment is working as it measures the amount of HIV in a sample of blood)
·         Between 100,000 and 1 million = High
·         Between 10,000 = for people with HIV not on treatment, this is low
·         Below 50 = known as an “undetectable” viral load. The aim of HIV treatment is to have an undetectable viral load also known as viral suppression.

·         CD4 and Viral load tests give essential information about the effects HIV is having on your immune health and hence your bodies response to infections and illness.
·         The aim of HIV treatment is to have a very low (or undetectable) viral load and a high CD4
·         When the CD4 count is low, the viral load is usually high. This situation is not good.
·         When the CD4 count is high, the viral load is usually low. This is much better.
·         If your CD4 count has dropped to 350 or below, it is recommended that you start ARV treatment.
·         The result of treatment should be that the CD4 is going up, and the viral load is going right down to undetectable levels.

HIV treatment
HIV treatment involves taking tablets (ARV’s) once or twice a day. ARV treatment stops the virus from reproducing and reduces the amount of HIV inside your body. If there is less HIV, there is less damage to your immune system, and you are less likely to get ill.

And if there is less HIV in your body fluids, you are less likely to pass on HIV (for example to a sexual partner, or to your unborn child during pregnancy).

The aim of HIV treatment is to have an ‘undetectable’ viral load – this means there is only a tiny amount of HIV in the body. ARV treatment is not a cure – they cannot totally wipe out HIV from your body.

HIV treatment helps you stay well by reducing the amount of HIV in the body. All ant-HIV drugs (ARV) try to prevent HIV infecting new cells. But different types of drugs do this in different ways. A combination of two to three different types of drugs provides a powerful attack on HIV. The aim of treatment is an “undetectable viral load” – very low levels of HIV in the blood.

Should I take HIV treatment?
Not everybody with HIV chooses to take anti-HIV drugs straightaway. Treatment will usually be recommended:
·         if your CD4 count is below 350,
·         if HIV is making you ill,
·         if you have another health condition such as hepatitis or TB,
·         if you are pregnant, or
·         if you want to take it in order to reduce the risk of passing HIV on to a sexual partner.

N.B: By knowing your status early you will give yourself enough time to find out about your options and make the right decisions in time.

Taking drugs on time
HIV treatment only works well if it is taken exactly as prescribed.

This is often called ‘adherence’, and it means taking the drugs:
·         at the right times,
·         at the right dose, and
·         following any advice about food and drink.

The nurses, pharmacists and doctors at your clinic can help you with this. You may need to develop a routine that helps you remember to take the drugs at the same time each day.

If you sometimes forget to take your pills, the drugs you are taking may stop working properly. If this happens you would need to change your treatment.

·         It is essential to take all your doses of HIV treatment at the right times and in the right amounts.
·         Taking anti-HIV (ARV’s) drugs regularly will mean that there is always enough of the drug in your body. This will keep HIV under control.
·         Not taking ARV’s as prescribed can result in HIV becoming resistant to the drug treatment choice you are on and can result in HIV being harder to treat in the future.

Looking after your health
As for anyone else, taking care of your health involves more than popping pills.
It will also help if you can:
·         Getting sufficient rest and sleep is important so that you can wind down and strengthen your immune system.
·         Eating a balanced diet to maintain a healthy weight gives you energy and ensures that you get the nutrients your body needs.
·         Get some exercise, which is good for the heart, lungs, circulation and mobility.
·         Give up smoking, if you are a smoker.
·         Talk to people and seek support (isolation and stress are bad for your health too).

As well as improving your physical health, all these things are good for your feelings and emotional wellbeing. For example, exercise can make you feel more relaxed and energised.

During difficult times, you may find that you use more alcohol or drugs. They may help you to forget, or to stop thinking about things. While they may offer temporary relief, relying on them is likely to make your feelings harder to deal with in the long run. Too much drink or drug use usually brings its own problems.

Seven ways to look after your health:
1.     Eat a balanced healthy diet
2.     Get some exercise
3.     If you are a smoker consider giving up smoking
4.     Get enough rest and sleep
5.     Talk to people and get a support for example: join a support group.
6.     Attending your clinic appointments and have regular blood tests.

7.     Take anti-HIV (ARV) drugs, if your blood tests show that you need to.