More efforts needed for universal access to services

17 APRIL 2007 | LONDON -- Access to antiretroviral therapy for advanced HIV infection in low- and middle-income countries continued to grow throughout 2006, with more than 2 million people living with HIV/AIDS receiving treatment in December 2006, a 54% increase over the 1.3 million people on treatment one year earlier in these countries. These encouraging findings were released today in a new report, “Towards universal access: scaling up priority HIV/AIDS interventions in the health sector,” published by WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and UNICEF.

At the same time, the report details a number of key areas in which efforts to scale up services are insufficient if the global goal of moving towards “universal access to comprehensive prevention programmes, treatment, care and support” for HIV by 2010 is to be achieved. For example, just 11% of HIV-positive pregnant women in need of antiretrovirals (ARVs) to prevent mother-to-child transmission of HIV (PMTCT) in low- and middle-income countries are receiving them. Global coverage of HIV testing and counselling remains unsatisfactorily low, as does coverage of prevention and treatment interventions for injecting drug users. And while countries committed themselves to setting targets for universal access by the end of 2006, only 90 had provided data on these by that date.

“The combined efforts of donors, affected nations, UN agencies and public health authorities are providing substantial, ongoing progress in access to HIV services,” said Dr Margaret Chan, Director-General, WHO. “Yet, in many ways we are still at the beginning of this commitment. We need ambitious national programmes, much greater global mobilization, and increased accountability if we are going to succeed."

Progress in access to HIV treatment

The report shows that countries in every region of the world are making substantial progress in increasing access to HIV treatment. More than 1.3 million people in sub-Saharan Africa were receiving treatment in December 2006, representing coverage of approximately 28% of those in need compared to just 2% in 2003. Coverage in other regions varied, from 6% in North Africa and the Middle East, to 15% in Eastern Europe and Central Asia and 72% in Latin America and the Caribbean. Overall, while encouraging trends continue, just 28% of the estimated 7.1 million people in need of treatment in all low- and middle-income countries were receiving it in December 2006.

Funding provided by the United States President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria was supporting 1 265 000 individuals receiving treatment by the end of 2006. The prices of most first-line ARVs decreased by between 37% and 53% in low- and middle-income countries from 2003 to 2006, and by between 10% and 20% from 2005 to 2006.

“The significant progress outlined in this report in scaling up access to treatment is a positive step forward for many countries in achieving their ambitious goals of universal access to HIV prevention, treatment, care and support,” said Dr Peter Piot, Executive Director of UNAIDS. “However new data in the report also shows that there is still a long way to go, particularly in the widespread provision of treatment to prevent mother to child transmission of HIV, which remains one of the simplest and cheapest proven prevention methods available,” he added.

The number of children receiving treatment increased by 50% in the past year, but from a very low base. In December 2006, only about 115 500 (15%) children of the 780 000 estimated to be in need of HIV treatment had access to it. According to HIV/AIDS Director in WHO, Dr Kevin De Cock, "urgent priorities are improving access to HIV treatment for children, especially in sub-Saharan Africa, as well as for injecting drug users everywhere". “Access to HIV testing and counselling, a critical entry point for both prevention and treatment services, also needs to be broadened significantly if we are to come near to reaching the targets for universal access by 2010," he added.

“Children continue to be the missing face of the AIDS pandemic,” said UNICEF Executive Director Ann M. Veneman, “with too many children still missing out on life-saving treatment and access to other essential services.” In 2005, UNICEF, UNAIDS and other partners launched the Unite for Children, Unite against AIDS campaign. It targets four key areas:

• prevention of mother to child transmission;
• treatment of paediatric AIDS;
• education programmes for prevention; and
• support for orphans and vulnerable children.

Challenges and recommendations

Among the report’s recommendations for improving the global AIDS response are the following:

Increase efforts to accelerate the prevention, diagnosis and treatment of HIV disease in children.

In addition to the need to increase treatment access, progress remains unsatisfactory in the prevention and diagnosis of HIV disease in children. The technical challenges of expanding services for children have been considerable. New approaches to overcoming these, such as the development of appropriate diagnostics and fixed-dose paediatric drug formulations, need to be more widely explored and accelerated.

Introduce a range of strategies to increase knowledge of HIV status.

Surveys in 12 high-burden countries in sub-Saharan Africa showed that a median of just 12% of men and 10% of women in the general population had been tested for HIV and received the results. While client-initiated voluntary counselling and testing (VCT) is helping people know their status, provider-initiated HIV testing and counselling (PITC) in health-care settings is emerging as a key additional strategy to expand access to HIV prevention, treatment and care services. The conditions under which testing and counselling are provided must also be improved in order to diminish obstacles to uptake, such as fear of stigma and negative reactions to disclosure.

Accelerate scale-up of services to prevent mother-to-child transmission of HIV (PMTCT).

More than 100 low- and middle-income countries have established PMTCT programmes, yet only seven were reaching 40% or more of HIV-infected pregnant women in 2005. In sub-Saharan Africa, where 85% of HIV-infected pregnant women live, coverage in countries ranges from less than 1% to 54%. Current efforts to prevent mother-to-child transmission of HIV are far below what is required to meet the UN target of reducing the proportion of children infected with HIV by 50% in 2010.

Improve access to services for most-at-risk populations, including injecting drug users and men who have sex with men (MSM).

Injecting drug use is a major mode of HIV transmission in several regions and is emerging as a concern in Africa. Adequate prevention, treatment, and care services need to be provided to this population if a significant impact is to be made on HIV transmission. Resurgent transmission of HIV and other sexually transmitted infections in MSM in industrialized countries needs to be countered, and prevention needs of MSM in low- and middle-income countries addressed.

Invest in prevention for people living with HIV/AIDS.

Persons living with HIV can be the strongest advocates for HIV prevention. Better follow-up is required of individuals diagnosed with HIV in voluntary counselling and testing centres. The health sector should provide a wider range of services and interventions to help people with HIV/AIDS to maximize their health, prevent and treat opportunistic and sexually transmitted infections, reduce the harms associated with injecting drug use, and avoid passing HIV on to others.

Improve access for people living with HIV/AIDS to quality TB prevention, diagnostic and treatment services.

Most cases of TB are preventable or curable. Nevertheless, almost 1 million people living with HIV will develop TB disease each year, leading to nearly a quarter of a million avoidable TB deaths. Chronic underinvestment and inadequate political commitment to TB control in many countries of high HIV prevalence have resulted in high TB incidence among people with HIV/AIDS and have contributed to the development of TB drug resistance. The emergence of extensively drug-resistant tuberculosis (XDR-TB) must now be urgently addressed through increased coordination and availability of prevention, diagnostic, and treatment services, and through comprehensive infection control strategies.

Recognize male circumcision as an important additional HIV prevention intervention.

Recent clinical trial data demonstrate a significant reduction in the risk of heterosexually acquired HIV infection among circumcised men. Male circumcision could have a major public health impact in countries where HIV prevalence is high, transmission is predominantly through heterosexual contact, and rates of male circumcision are low. Such countries should urgently consider scaling up access to safe male circumcision services. Key issues in implementation include the quality and safety of services, cultural considerations, and adherence to human rights principles in the provision of male circumcision, including informed consent, confidentiality, and absence of coercion.

Address concerns about longer-term financial sustainability.

Financial concerns, especially with reference to what will be available from major multilateral and bilateral sources in the long term, continue to limit the scope and rate of scale-up in many countries and threaten long-term sustainability. While encouraging reductions have occurred in the price of first-line regimens in most low- and some middle-income countries, the demand for expensive second-line regimens will continue to increase. Unless prices for second-line regimens fall significantly, budgetary constraints may put treatment programmes at risk.