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ACCESS TO UNIVERSAL HIV CARE AND PREVENTION SERVICES: LIGHT AT THE END OF A LONG TUNNEL?

Sunday, 15th of July 2012

• ACCESS TO UNIVERSAL HIV CARE AND PREVENTION SERVICES: LIGHT AT THE END OF A LONG TUNNEL?

Frederick K. Sawe

Clin Infect Dis. (2012) 54 (1): 119-120. doi: 10.1093/cid/cir796 First

+ Author Affiliations

HIV Program, Kenya Medical Research Institute/Walter Reed Project, Kericho

Correspondence: Fredrick Sawe, MBChB, MMED, Kenya Medical Research Institute/Walter Reed Project, Hospital Rd, PO Box 1357-20200, Kericho, Kenya (fsawe@wrp-kch.org).

Also at http://cid.oxfordjournals.org/content/54/1/119.full

(See the article by Jarrin et al, on pages 111–8.)

There has been a rapid scaling-up of human immunodeficiency virus (HIV) prevention and care services globally in the last 10 years, with falling rates of new HIV infections and >6.6 million of the 15 million people who need antiretroviral therapy (ART) currently receiving it [1]. Recent studies have demonstrated the efficacy of antiretrovirals when used for prevention [2], and the promising results of the RV144 HIV vaccine trial [3] have boosted HIV prevention efforts. However, much still remains to be done: More efficacious HIV infection prevention interventions; therapeutic drugs that are less toxic, durable, and easier to take; and improved models of healthcare delivery are urgently needed. The challenges going forward remain enormous: Approximately 33.3 million people were living with HIV at the end of 2009, with 1.8 million new HIV infections and 2.6 million deaths due to HIV in that year, most of them in resource-limited settings (RLSs) [4]. With a shortage of approximately 10 billion dollars in HIV/AIDS funding in an era when funding is either declining or has flat-lined, HIV/AIDS programs in RLSs would have to choose priorities [1]. HIV/AIDS morbidities and mortalities are high in RLSs because of late presentations of patients for care, coupled with weak and fragile healthcare systems. Without aggressive and effective universal HIV infection prevention programs, HIV/AIDS treatment as it is currently implemented in RLSs is not sustainable.

In this issue Jarrin and colleagues describe their findings from the Concerted Action on SeroConversion to AIDS and Death in Europe (CASCADE) study. The CASCADE study examined the uptake of combination antiretroviral therapy (cART) and HIV disease progression to AIDS, initiation of ART, and death according to geographical origin in subjects with known dates of seroconversion after they had migrated to or were originally from the West (European Union, United States, Canada, Australia, and New Zealand). The study showed that in settings where there is universal access to healthcare, migrants living in the West when they seroconverted, who were originally from North Africa and the Middle East, sub-Saharan Africa, Latin America, and Asia had similar outcomes in the risk of AIDS and death compared to those living or originally from the West. However, seroconverters from North Africa, the Middle East, and sub-Saharan Africa appeared to have lower mortality risks than those from the West. The seroconverters from sub-Saharan Africa were also more likely to initiate cART than those from the West.

The above findings by Jarrin and colleagues are very encouraging for the public health approach to scaling up HIV/AIDS continuum of prevention and care in RLSs in support of the World Health Organization/Joint United Nations Programme on HIV/AIDS plan for universal access to HIV prevention and care services. This calls for innovation and adaptations of such results to local settings through a radical shift in emphasis to simplification, innovation in drug design, diagnostics, cost savings, adapted healthcare delivery systems, renewed commitment, and resources that will be crucial in reaching universal and sustainable coverage of HIV prevention and treatment services. Other interventions to expand HIV services include the scaling up of HIV testing to identify all who are in need of HIV prevention and treatment; early and timely initiation of ART; and improvement of the healthcare infrastructure to include decentralization, networking, and integration of HIV/AIDS services with other existing healthcare programs [5].

Jarrin and colleagues analyzed a cohort of HIV-infected patients with known times of seroconversion while living in the West. The role of acute/early HIV infections in the transmission of HIV infection and understanding the pathogenesis of acute/early HIV (and hence important data for HIV prevention trials including vaccines) is crucial [5]. Given that patients with acute infections are at highest risk of HIV transmission and may be responsible for up to 50% of all new infections, this information is critical [6–8]. Not much has been done to deal with this problem in current HIV programs in RLSs; further research in RLSs is needed.

Research and experience from RLSs has shown a high loss to follow-up (LTFU) rate between HIV diagnosis, pre- and post-ART care enrollment, and follow-up, leading to rapid disease progression, late presentation at initiation of ART, high opportunistic disease burden, and accompanying high morbidity and mortality [9]. Although LTFU was generally high for all groups in the CASCADE study, it is encouraging that the study shows significantly lower LTFU by subjects who were originally from sub-Saharan Africa. Innovative strategies are needed to address these challenges of LTFU and high mortality at initiation of ART in RLSs. These include earlier HIV diagnosis and ART initiation, screening and prophylaxis for opportunistic infections, optimized diagnosis and management of specific diseases and treatment of complications, and program strengthening. Access to HIV prevention and care services by those who need HIV treatment in RLSs is faced with many challenges and barriers, including availability of the services, fear of stigma and discrimination, transportation costs, user fees, and access to food [10].

In summary, scaling up of programs to diagnose and treat HIV infection early to improve quality of life as part of a comprehensive care package of combination HIV infection prevention based on proven, well-tested clinical trials can reduce HIV/AIDS-related morbidities and deaths and control the epidemic, especially in RLSs, until an affordable, safe, and globally effective HIV vaccine is found.