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Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a public health approach.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2012 Apr.  p.These guidelines recommend increasing the offering of HIV testing and counselling (HTC) to couples and partners, with support for mutual disclosure. They also recommend offering antiretroviral therapy (ART) for HIV prevention in serodiscordant couples. Recommendations include: 1.Couples and partners should be offered voluntary HIV testing and counselling with support for mutual disclosure (Strong recommendation, low-quality evidence). 2. Couples and partners in antenatal care settings should be offered voluntary HIV testing and counselling with support for mutual disclosure (Strong recommendation, low-quality evidence). 3. Couples and partner voluntary HIV testing and counselling with support for mutual disclosure should be offered to individuals with known HIV status and their partners (Strong recommendation, low-quality evidence for all people with HIV in all epidemic settings / Conditional recommendation, low-quality evidence for HIV-negative people depending on country-specific HIV prevalence). 4. People with HIV in serodiscordant couples and who are started on antiretroviral therapy (ART) for their own health should be advised that ART is also recommended to reduce HIV transmission to the uninfected partner (Strong recommendation, high-quality evidence). 5. HIV-positive partners with >350 CD4 cel ls/µL in serodiscordant couples should be offered ART to reduce HIV transmission to uninfected partners (Strong recommendation, high-quality evidence. (Excerpts)
Prioritizing second-line antiretroviral drugs for adults and adolescents: a public health approach. Report of a WHO working group meeting, World Health Organization, HIV Department, Geneva, Switzerland, 21-22 May 2007.
Geneva, Switzerland, WHO, 2007. 43 p.Antiretroviral therapy has dramatically improved the survival of HIV infected individuals and is critically needed to save millions of lives. As resource-limited countries rapidly expand their HIV/AIDS treatment programmes, increasingly countries are faced with the need to make second-line ART regimens available. The 2006 WHO ARV treatment guidelines outline the strategic approaches that should inform updated national treatment guidelines for first- and second-line therapies, and outline which agents should be considered for use in first line and second line. National programmes, however, are requesting additional operational guidance on the composition of their 2nd line ART formularies based on programmatic efficiencies and costs. As the ARV formulary is generally limited in developing countries, there is an increasing and urgent need for principles and criteria by which to prioritize ARV options. Regulatory bodies both nationally and internationally (e.g. the WHO pre-qualification project) are also requesting guidance on how to select the most needed therapeutic ARV agents for rapid appraisal. WHO therefore convened an expert meeting to review the scientific evidence and programmatic data available, in order to develop guidance for national programmes, regulatory authorities and implementing partners on selection, prioritization and planning for second-line ARV drugs. (excerpt)
The evolving cost of HIV in South Africa: Changes in health care cost with duration on antiretroviral therapy for public sector patients.
Journal of Acquired Immune Deficiency Syndromes. 2007 Jul; 45(3):348-354.A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. t-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs. (author's)
The continuum of care for people living with HIV / AIDS in Cambodia: linkages and strengthening in the public health system. Case study.
Manila, Philippines, World Health Organization [WHO], Regional Office for the Western Pacific, 2006. 30 p.HIV/AIDS is a multifactorial disease requiring life-long treatment. In 2003, Cambodia released its plan to meet this need -- the comprehensive Continuum of Care (CoC) -- which is an integrated provision of treatment for people living with HIV/AIDS (PLHA). In three short years, Cambodia's National Center for HIV/AIDS and STI (NCHADS) has started and expanded this country-devised and country-led activity. By the end of 2005, it was reaching 20 out of the country's 68 operational districts (ODs), including free antiretroviral treatment (ART) for 11,284 PLHA out of the estimated 19,184 adult Cambodians who currently need it. Additionally 1,071 children are receiving ART. This case study provides a snapshot of the CoC as it is in the middle of this rapid expansion. It is also an investigation of possible health system strengthening effects achieved by the CoC. In general, the four provinces included in the study had a common understanding of the multiple elements that make up the CoC, despite their varying levels of outside support from non-governmental organizations (NGOs) and donors for implementation. (excerpt)
The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings.
Lancet. 2006 Aug 5; 368(9534):505-510.WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system. (author's)
Potential impact of antiretroviral therapy on HIV-1 transmission and AIDS mortality in resource-limited settings.
Journal of Acquired Immune Deficiency Syndromes. 2006 Apr 15; 41(5):632-641.The objective was to estimate the potential impact of antiretroviral therapy on the heterosexual spread of HIV-1 infection and AIDS mortality in resource-limited settings. A mathematic model of HIV-1 disease progression and transmission was used to assess epidemiologic outcomes under different scenarios of antiretroviral therapy, including implementation of World Health Organization guidelines. Implementing antiretroviral therapy at 5% HIV-1 prevalence and administering it to 100% of AIDS cases are predicted to decrease new HIV-1 infections and cumulative deaths from AIDS after 10 years by 11.2% (inter-quartile range [IQR]: 1.8%-21.4%) and 33.4% (IQR: 26%-42.8%), respectively. Later implementation of therapy at endemic equilibrium (40% prevalence) is predicted to be less effective, decreasing new HIV-1 infections and cumulative deaths from AIDS by 10.5% (IQR: 2.6%-19.3%) and 27.6% (IQR: 20.8%-36.8%), respectively. Therapy is predicted to benefit the infected individual and the uninfected community by decreasing transmission and AIDS deaths. The community benefit is greater than the individual benefit after 25 years of treatment and increases with the proportion of AIDS cases treated. Antiretroviral therapy is predicted to have individual and public health benefits that increase with time and the proportion of infected persons treated. The impact of therapy is greater when introduced earlier in an epidemic, but the benefit can be lost by residual infectivity or disease progression on treatment and by sexual disinhibition of the general population. (author's)
Lancet. 2005 Oct 1; 366:1138.Zimbabwe is in crisis. Since May, Operation Murambatsvina (“drive away rubbish”) has led to the forced evictions and demolition of communities countrywide, leaving hundreds of thousands of people homeless. This mass destruction has exacerbated the problems of drought and malnutrition, increased the devastation of HIV/AIDS, and worsened national economic meltdown. A UN report has estimated that over 79 500 people with HIV/AIDS were among those evicted, disrupting home-based care, and Zimbabwe’s antiretroviral programme. The crucial issue of adherence to drug regimens has been seriously threatened. In public-sector antiretroviral programmes, it is estimated that 30% of patients have experienced a break in drug supplies of at least 2 weeks. 2 weeks is enough to further the development of clinically significant resistance to nevirapine, the cornerstone of the government’s firstline antiretroviral protocol. Interruption in treatment— coupled with the disruption to social and safety mechanisms, overcrowding, lack of access to clean water, food, and shelter, especially with the onset of winter looming—make the sick even more vulnerable. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach. Executive summary.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002 Apr. 31 p.Currently, fewer than five per cent of those who require ARV treatment can access these medicines in resource limited settings. WHO believes that at least three million people needing care should be able to get medicines by 2005—a more than ten-fold increase. These guidelines are intended to support and facilitate the proper management and scale-up of ART in the years to come by proposing a public health approach to achieve these goals. The key tenets of this approach are: 1) Scaling up of antiretroviral treatment programmes to meet the needs of people living with HIV/AIDS in resource-limited settings; 2) Standardization and simplification of ARV regimens to support the efficient implementation of treatment programmes; 3) Ensuring that ARV treatment programmes are based on the best scientific evidence, in order to avoid the use of substandard treatment protocols which compromise the treatment outcome of individual clients and create the potential for emergence of drug resistant virus. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach.
Geneva, Switzerland, WHO, Department of HIV / AIDS, 2002. 163 p.These guidelines are part of the World Health Organization’s commitment to the global scale-up of antiretroviral therapy. Their development involved international consultative meetings throughout 2001, in which more than 200 clinicians, scientists, government representatives, representatives of civil society and people living with HIV/AIDS from more than 60 countries participated. The recommendations included in this document are largely based on a review of evidence and reflect the best current practices. Where the body of evidence was not conclusive, expert consensus was used as a basis for recommendations. We hope that this guidance will help Member countries as they work towards meeting the global target of having three million people on antiretroviral therapy by 2005. (excerpt)
Geneva, Switzerland, UNAIDS, 2003. Prepared for the 2nd Meeting of the UNAIDS Global Reference Group on HIV / AIDS and Human Rights, August 25-27, 2003. 3 p.Over 20 years ago, policy and programmatic approaches to HIV testing emerged in a context of great fear about HIV/AIDS and about how to prevent HIV infected individuals from transmitting the virus. As testing methods were developed, HIV testing assumed an important role in epidemiological surveillance, and as treatment became available, on individual testing for clinical purposes. Yet, as national responses to the emerging epidemics unfolded, numerous States argued that the protection of public health warranted compulsory testing requirements of certain populations considered to be “high risk”, mandatory testing for access to certain goods and services, named reporting of those found to be infected and sometimes contact tracing and mandatory notification of partners, family, employers or community members. The realities of stigma, discrimination and the neglect of human rights protections were recognized to keep people away from prevention and care, and creating fertile ground for people not to get tested and, unaware of their HIV status, to further spread the virus. This recognition lead to a bridge between those concerned with human rights protections and those concerned with public health imperatives. Over time, the components of supportive testing became clearer, the concept of voluntary counseling and testing (VCT) was promulgated and policy direction from GPA/WHO centered on making voluntary counseling and testing an important focus of all national responses to the HIV/AIDS epidemics. This policy, further elaborated by WHO and UNAIDS remains in place today. (excerpt)
Lancet. 2004 Dec 4; 364:2007-2008.Mikhail Rukavishnikov sits in his modern apartment in central Moscow sipping tea. To the casual visitor he has all the trappings of Russia’s emerging middle class who have overcome the chaos of the 1990s and made a comfortable life. He has an office job with a big Russian firm, a decent apartment, a big TV, and money to travel abroad on holiday. But Rukavishnikov and his girlfriend are among the million Russians living with HIV. “I toyed with drugs when I was younger and got infected. We had no idea then of the dangers. We had never heard about HIV/AIDS and Russian awareness is still catching up with the rest of the world”, says Rukavishnikov. Drug abuse in Russia is rampant and is still the main route of HIV transmission, but the spread of the disease has reached a critical point: public-health officials warn that the virus has begun to move from the high-risk groups such as drug users, sex workers, and prisoners, to a bridge population. A recent report by UNAIDS says the Russian epidemic is growing out of control, as infection spreads faster than in any European country. (excerpt)
Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach. Rev. ed.
Geneva, Switzerland, WHO, 2003. 67 p.Currently, fewer than 5% of people in developing countries who need ART can access the medicines in question. WHO believes that at least 3 million people needing care should be able to get the medicines by 2005. This represents almost a tenfold increase. These treatment guidelines are intended to support and facilitate the proper management and scale-up of ART in the years to come by proposing a public health approach to achieve the goals. The key tenets of this approach are as follows. 1) Scaling-up of antiretroviral treatment programmes with a view to universal access, i.e. all persons requiring treatment as indicated by medical criteria should have access to it. 2) Standardization and simplification of ARV regimens so as to support the efficient implementation of treatment programmes in resource-limited settings. 3) Ensuring that ARV treatment programmes are based on scientific evidence in order to avoid the use of substandard protocols that compromise the outcomes of individual patients and create a potential for the emergence of drug-resistant virus. However, it is also important to consider the realities with respect to the availability of human resources, health system infrastructures and socioeconomic contexts so that clear and realistic recommendations can be made. (excerpt)
Lancet. 2003 Dec 6; 362(9399):1900-1901.WHO (world health organization) Director-General Lee Jongwook is unapologetic about the UN health agency’s revolutionary goal of getting 3 million people in poor countries on antiretroviral treatment by 2005—an ambitious target even by the standards of idealists. But the South Korean infectious disease specialist says it was hardnosed realism rather than dreams that prompted him to adopt the “3 by 5” campaign—which is expected to need US$5·5 billion in new funds over the next 2 years—as the centerpiece of his leadership of the UN health agency. (excerpt)