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AIDS. 2016 Nov 28; 30(18):2865-2873.OBJECTIVE: In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/mul in four resource-limited countries (South Africa, Nigeria, Uganda, and India). DESIGN: A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/mul initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/mul were met. METHODS: The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds. RESULTS: Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions. CONCLUSIONS: In HIV-positive patients with CD4 counts above 500 cells/mul in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
Oral Diseases. 2016 Apr; 22 Suppl 1:42-5.Four million people of the global total of 35 million with HIV infection are from South-East Asia. ART is currently utilized by 15 million people and has led to a dramatic decline in the mortality rate, including those in low- and middle-income countries. A reduction in sexually transmitted HIV and in comorbidities including tuberculosis has also followed. Current recommendations for the initiation of antiretroviral therapy in people who are HIV+ are essentially to initiate ART irrespective of CD4 cell count and clinical stage. The frequency of HIV testing should be culturally specific and based on the HIV incidence in different key populations but phasing in viral load technology in LMIC is an urgent priority and this needs resources and capacity. With the availability of simplified potent ART regimens, persons with HIV now live longer. The recent WHO treatment guidelines recommending routine HIV testing and earlier initiation of treatment should be the stepping stone for ending the AIDS epidemic and to meet the UNAIDS mission of 90*90*90. (c) 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
[HIV-1 resistance to antiretroviral drugs in pregnant women from Buenos Aires metropolitan area] Resistencia de HIV-1 a drogas antirretrovirales en gestantes del area Metropolitana de Buenos Aires.
Medicina. 2016; 76(6):349-354.The study aimed to determine the prevalence of antiretroviral resistance associated mutations in HIV-1 infected pregnant woman treated in Buenos Aires metropolitan area (period 2008-2014). A total of 136 women with viral load = 500 copies/ml were included: 77 (56.6%) were treatment-naive and 59 (43.4%) were antiretroviral-experienced patients either with current (n: 24) or previous (n = 35) antiretroviral therapy. Genotypic baseline resistance was investigated in plasma of antiretroviral-naive patients and antiretroviral-experienced patients. The resistance mutations were identified according to the lists of the World Health Organization and the International Antiviral Society, respectively. Frequencies of resistance associated mutations detected in 2008-2011 and 2012-2014 were compared. A total of 37 (27.2%) women presented at least one resistance associated mutation: 25/94 (26.5%) in 2008-2011 and 12/42 (28.5%) in 2012-2014 (p > 0.05). Among naives, 15 (19.5%) had at least one mutation: 10/49 (20.4%) in the period 2008-2011 and 5/28 (17.8%) in 2012-2014 (p > 0.05). The resistance mutations detected in naives were associated with non nucleoside reverse transcriptase inhibitors, being K103N the most common mutation in both periods. In antiretroviral experienced patients, 22/59 (37.3%) had at least one resistance mutation. This study demonstrates a high frequency of resistance associated mutations which remained stable in the period analyzed. These levels suggest an increased circulation of HIV-1 antiretroviral resistant strains in our setting compared to previous reports from Argentina.
Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study.
BMC Infectious Diseases. 2016 Apr 29; 16:189.BACKGROUND: Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya). METHODS: A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women. RESULTS: After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %. CONCLUSIONS: The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.
Southern African Journal of HIV Medicine. 2016; 17(1): p.Background: The World Health Organization (WHO) HIV treatment guidelines have been used by various countries to revise their national guidelines. Our study discusses the national policy response to the HIV epidemic in sub-Saharan Africa and quantifies delays in adopting the WHO guidelines published in 2009, 2013 and 2015. Methods: From the Internet, health authorities and experts, and community members, we collected 59 published HIV guidelines from 33 countries in the sub-Saharan African region, and abstracted dates of publication and antiretroviral therapy (ART) eligibility criteria. For these 33 countries, representing 97% regional HIV burden in 2015, the number of months taken to adopt the WHO 2009, 2013 and/or 2015 guidelines were calculated to determine the average delay in months needed to publish revised national guidelines. Findings: Of the 33 countries, 3 (6% regional burden) are recommending ART according to the WHO 2015 guidelines (irrespective of CD4 count); 19 (65% regional burden) are recommending ART according to the WHO 2013 guidelines (CD4 count = 500 cells/mm3); and 11 (26% regional burden) according to the WHO 2009 guidelines (CD4 count = 350 cells/mm3). The average time lag to WHO 2009 guidelines adoption in 33 countries was 24 (range 3–56) months. The 22 that have adopted the WHO 2013 guidelines took an average of 10 (range 0–36) months, whilst the three countries that adopted the WHO 2015 guidelines took an average of 8 (range 7–9) months. Conclusion: There is an urgent need to shorten the time lag in adopting and implementing the new WHO guidelines recommending ‘treatment for all’ to achieve the 90-90-90 targets.
Progress with Scale-Up of HIV Viral Load Monitoring - Seven Sub-Saharan African Countries, January 2015-June 2016.
MMWR. Morbidity and Mortality Weekly Report. 2016 Dec 02; 65(47):1332-1335.The World Health Organization (WHO) recommends viral load testing as the preferred method for monitoring the clinical response of patients with human immunodeficiency virus (HIV) infection to antiretroviral therapy (ART) (1). Viral load monitoring of patients on ART helps ensure early diagnosis and confirmation of ART failure and enables clinicians to take an appropriate course of action for patient management. When viral suppression is achieved and maintained, HIV transmission is substantially decreased, as is HIV-associated morbidity and mortality (2). CDC and other U.S. government agencies and international partners are supporting multiple countries in sub-Saharan Africa to provide viral load testing of persons with HIV who are on ART. This report examines current capacity for viral load testing based on equipment provided by manufacturers and progress with viral load monitoring of patients on ART in seven sub-Saharan countries (Cote d'Ivoire, Kenya, Malawi, Namibia, South Africa, Tanzania, and Uganda) during January 2015-June 2016. By June 2016, based on the target numbers for viral load testing set by each country, adequate equipment capacity existed in all but one country. During 2015, two countries tested >85% of patients on ART (Namibia [91%] and South Africa [87%]); four countries tested <25% of patients on ART. In 2015, viral suppression was >80% among those patients who received a viral load test in all countries except Cote d'Ivoire. Sustained country commitment and a coordinated global effort is needed to reach the goal for viral load monitoring of all persons with HIV on ART.
New York, New York, UNICEF, 2016 Dec. 92 p.Despite remarkable achievements in the prevention and treatment of HIV, this report finds that progress has been uneven globally. In 2015, more than half of the world’s new infections (1.1 million out of 2.1 million) were among women, children and adolescents, and nearly 2 million adolescents aged 10-19 were living with HIV. In sub-Saharan Africa, the region most impacted by HIV, three in four new infections in 15-19-year-olds were among girls. The report proposes strategies for preventing HIV among women, children and adolescents who have been left behind, and treating those who are living with HIV.
Get on the fast-track. The life-cycle approach to HIV. Finding solutions for everyone at every stage of life.
Geneva, Switzerland, UNAIDS, 2016. 140 p.In this report, UNAIDS is announcing that 18.2 million people now have access to HIV treatment. The Fast-Track response is working. Increasing treatment coverage is reducing AIDS-related deaths among adults and children. But the life-cycle approach has to include more than just treatment. Tuberculosis (TB) remains among the commonest causes of illness and death among people living with HIV of all ages, causing about one third of AIDS-related deaths in 2015. These deaths could and should have been prevented. TB, like cervical cancer, hepatitis C and other major causes of illness and death among people living with HIV, is not always detected in HIV services. It is vital that we collaborate closely with other health programmes to prevent unnecessary deaths. The impact of better treatment coverage means that a growing number of people will be living with HIV into old age, while there has also been an increase in new HIV infections among older people. The consequences of long-term antiretroviral therapy, combined with the diseases of ageing, will be new territory for many HIV programmes. Drug resistance is a major threat to the AIDS response, not just for antiretroviral medicines but also for the antibiotic and antituberculous medicines that people living with HIV frequently need to remain healthy. More people than ever before are in need of second- and third-line medicines for HIV and TB. The human burden of drug resistance is already unacceptable; the financial costs will soon be unsustainable. We need to make sure the medicines we have today are put to best use, and accelerate and expand the search for new treatments, diagnostics, vaccines and an HIV cure. As we build on science and innovation we will need fresh thinking to get us over the remaining obstacles. The cliché is true -- what got us here, won’t get us there. We face persistent inequalities, the threat of fewer resources and a growing conspiracy of complacency. (Excerpt)
Expert Review of Clinical Pharmacology. 2016 Aug 22; 9(11):1493-1503.Introduction: WHO recommends tenofovir, efavirenz, and lamivudine or emtricitabine for first-line antiretroviral therapy (ART) in adults, which replaced more toxic regimens using stavudine, zidovudine or nevirapine. Areas covered: We searched Pubmed to identify observational studies and randomized controlled trials reporting toxicity of these antiretrovirals published between 2011 and 2016, and hand-searched abstracts presented at major HIV conferences in 2015 and 2016, focusing on data from sub-Saharan Africa. Tenofovir’s nephrotoxicity manifests as mild renal tubular dysfunction (common and of uncertain clinical significance), acute kidney injury (rare), and chronic declining glomerular filtration rate (common). African studies, which include high proportions of patients with renal dysfunction from opportunistic diseases, report population improvement in renal function after starting tenofovir-based ART. Tenofovir modestly decreases bone mineral density, and there is emerging data that this increases fracture risk. Efavirenz commonly causes early self-limiting neuropsychiatric toxicity and hypersensitivity rashes. Recent studies have highlighted its long-term neuropsychiatric effects, notably suicidality and neurocognitive impairment, and metabolic toxicities (dyslipidemia, dysglycemia, and lipoatrophy). We point out the challenges clinicians face in the recognition and attribution of adverse drug reactions. Expert commentary: Tenofovir and efavirenz are generally well tolerated, but both are associated with potentially serious toxicities. Pharmacovigilance systems in resource-limited settings with high HIV burden should be strengthened.
Short Communication: Population-Based Surveillance of HIV-1 Drug Resistance in Cameroonian Adults Initiating Antiretroviral Therapy According to the World Health Organization Guidelines.
AIDS Research and Human Retroviruses. 2016 Apr; 32(4):329-33.With ongoing earlier enrollment on and rapid scale-up of antiretroviral therapy (ART) in Cameroon, there are increasing risks of transmitted HIV drug resistance (HIVDR) at population levels. We, therefore, evaluated the threshold of HIVDR in a population initiating ART, to inform on the effectiveness of first-line regimens, considering HIV-1 diversity, plasma viral load (PVL), and CD4-based disease progression. A total of 53 adults [median (interquartile range, IQR) CD4: 162 cell/mm(3) (48-284); median (IQR) PVL: 5.34 log10 RNA (4.17-6.42) copies/ml] initiating ART in 2014 at the Yaounde Central Hospital were enrolled for HIV-1 protease-reverse transcriptase sequencing. Drug resistance mutations (DRMs) were interpreted using the 2009 World Health Organization (WHO) list versus the Stanford HIVdb algorithm version 7.0. Level of DRMs was low (3.77%) versus moderate (7.55%), respectively, following the WHO list (T69D, K103N) versus Stanford HIVdb (T69D, A98G, K103N, K238T), respectively. Prevailing clade was CRF02_AG (71.70%). Based on Stanford HIVdb, a slightly higher proportion of patients with DRMs were found among ones infected with CRF02_AG than in those non-CRF02_AG infected (7.89% vs. 6.67%, p = 1.000), with lower PVL (7.69% <5.5 vs. 0% >/=5.5 log10 RNA copies/ml, p = .488) and with higher CD4 counts (9.52% CD4 >/=200 vs. 3.33% CD4 <200 cells/mm(3), p = .749). Thresholds of DRMs suggest that standard first-line regimens currently used in Cameroon may remain effective at population levels, despite scale-up of ART in the country, pending adherence, and closed virological monitoring. With an intent-to-diagnose approach, the discrepant levels of DRMs support using Stanford HIVdb to evaluate initial ART, while revising the WHO list for surveillance.
Performance of Risk Charts to Guide Targeted HIV Viral Load Monitoring of ART: Applying the Method on the Data From a Multicenter Study in Rural Lesotho.
Journal of Acquired Immune Deficiency Syndromes. 2016 May 1; 72(1):e22-5.Add to my documents.
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. 2nd ed.
Geneva, Switzerland, WHO, 2016.  p.These guidelines provide guidance on the diagnosis of human immunodeficiency virus (HIV) infection, the use of antiretroviral (ARV) drugs for treating and preventing HIV infection and the care of people living with HIV. They are structured along the continuum of HIV testing, prevention, treatment and care. This edition updates the 2013 consolidated guidelines on the use of antiretroviral drugs following an extensive review of evidence and consultations in mid-2015, shared at the end of 2015, and now published in full in 2016. It is being published in a changing global context for HIV and for health more broadly.
Geneva, Switzerland, UNAIDS, 2016.  p.Efforts to reach fewer than 500 000 new HIV infections by 2020 are off track. This simple conclusion sits atop a complex and diverse global tapestry. Data from 146 countries show that some have achieved declines in new HIV infections among adults of 50% or more over the last 10 years, while many others have not made measurable progress, and yet others have experienced worrying increases in new HIV infections.
Global Public Health. 2016 Aug 6; 1-15.The drive for universal health coverage (UHC) now has a great deal of normative impetus, and in combination with the inauguration of the sustainable development goals, has come to be regarded as a means of ensuring the financial basis for the struggle against HIV and AIDS. The argument of this paper is that such thinking is a case of ‘the right thing at the wrong time’: it seriously underestimates the scale of the work against HIV and AIDS, and the speed with which we need to undertake it, if we are to consolidate the gains we have made to date, let alone reduce it to manageable proportions. The looming ‘fiscal crunch’ makes the challenges all the more daunting; even in the best circumstances, the time required to establish UHCs capable of providing both essential health services and a very rapid scale-up of the fight against HIV and AIDS is insufficient when set against the urgency of ensuring that AIDS does not eventuate as a global health catastrophe.
Guideline: Updates on HIV and infant feeding. The duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV.
Geneva, Switzerland, WHO, 2016.  p.The objective of this guideline is to improve the HIV-free survival of HIV-exposed infants by providing guidance on appropriate infant feeding practices and use of ARV drugs for mothers living with HIV and by updating WHO-related tools and training materials. The guideline is intended mainly for countries with high HIV prevalence and settings in which diarrhoea, pneumonia and undernutrition are common causes of infant and child mortality. However, it may also be relevant to settings with a low prevalence of HIV depending on the background rates and causes of infant and child mortality. This guideline aims to help Member States and their partners in their efforts to make informed decisions on the appropriate nutrition actions to achieve the Sustainable Development Goals, the global targets set in the comprehensive implementation plan on maternal, infant and young child nutrition, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the Global Health Sector Strategy on Sexually Transmitted Infections 2016-2021. The target audience for this guideline includes: (1) national policy-makers in health ministries; (2) programme managers working in child health, essential drugs and health worker training; (3) health-care providers, researchers and clinicians providing services to pregnant women and mothers living with HIV at various levels of health care; and (4) development partners providing financial and/or technical support for child health programmes, including those in conflict and emergency settings. (Excerpt)
Geneva, Switzerland, UNAIDS, 2016.  p.This report highlights best practices and provides examples of countries that are already coming close to achieving the 90–90–90 targets, which are that 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads. The report outlines steps that are needed to expedite gains towards each of the three 90s. Technological and service delivery innovations rapidly need to be brought to scale, communities must be empowered to lead the push to end the epidemic, new resources must be mobilized to reach the final mile of the response to HIV and steps must urgently be taken to eliminate social and structural barriers to service access.
Targeted Spontaneous Reporting: Assessing Opportunities to Conduct Routine Pharmacovigilance for Antiretroviral Treatment on an International Scale.
Drug Safety. 2016 Jun 9; 1-18.Introduction: Targeted spontaneous reporting (TSR) is a pharmacovigilance method that can enhance reporting of adverse drug reactions related to antiretroviral therapy (ART). Minimal data exist on the needs or capacity of facilities to conduct TSR. Objectives: Using data from the International epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, the present study had two objectives: (1) to develop a list of facility characteristics that could constitute key assets in the conduct of TSR; (2) to use this list as a starting point to describe the existing capacity of IeDEA-participating facilities to conduct pharmacovigilance through TSR. Methods: We generated our facility characteristics list using an iterative approach, through a review of relevant World Health Organization (WHO) and Uppsala Monitoring Centre documents focused on pharmacovigilance activities related to HIV and ART and consultation with expert stakeholders. IeDEA facility data were drawn from a 2009/2010 IeDEA site assessment that included reported characteristics of adult and pediatric HIV care programs, including outreach, staffing, laboratory capacity, adverse event monitoring, and non-HIV care. Results: A total of 137 facilities were included: East Africa (43); Asia–Pacific (28); West Africa (21); Southern Africa (19); Central Africa (12); Caribbean, Central, and South America (7); and North America (7). Key facility characteristics were grouped as follows: outcome ascertainment and follow-up; laboratory monitoring; documentation—sources and management of data; and human resources. Facility characteristics ranged by facility and region. The majority of facilities reported that patients were assigned a unique identification number (n = 114; 83.2 %) and most sites recorded adverse drug reactions (n = 101; 73.7 %), while 82 facilities (59.9 %) reported having an electronic database on site. Conclusion: We found minimal information is available about facility characteristics that may contribute to pharmacovigilance activities. Our findings, therefore, are a first step that can potentially assist implementers and facility staff to identify opportunities and leverage their existing capacities to incorporate TSR into their routine clinical programs.
Geneva, Switzerland, UNAIDS, 2016.  p. (UNAIDS/JC2842/E)This document gives an update on progress in the Fast-Track Strategy, adopted by the UNAIDS Programme Coordinating Board in October 2015. This strategy sets HIV service coverage targets that must be achieved by 2020 to build sufficient momentum to overcome one of history's greatest public health threats by 2030. For example: Providing antiretroviral therapy (ART) to an additional 12 million people living with HIV in 2020. This will require reaching key populations with a comprehensive package of HIV services. Increasing investment in HIV programs from an estimated USD$19.2 billion in 2014 to USD$26.2 billion by 2020. After 2020, the vast majority of people living with HIV will have been diagnosed. Because of this and other factors, the resources needed for HIV will then steadily decrease to USD$22.3 billion in 2030. Increasing investment in outreach to key populations in low- and middle-income countries for HIV prevention and linkage to HIV testing and treatment. This investment should grow to about 7.2 percent of total investment by 2020, and the estimated resources needed for community-based delivery of ART percent should grow to about 3.8 percent of total investment. The report also states that international assistance should continue to focus on low-income countries, which are less able to fund their HIV response.
Implementation and Operational Research: Implementation of the WHO 2011 Recommendations for Isoniazid Preventive Therapy (IPT) in Children Living With HIV/AIDS: A Ugandan Experience.
Journal of Acquired Immune Deficiency Syndromes. 2016 Jan 1; 71(1):e1-8.BACKGROUND: Intensified tuberculosis (TB) case finding and isoniazid preventive therapy (IPT) are strongly recommended for children who are HIV infected. Data are needed to assess the feasibility of the WHO 2011 intensified tuberculosis case finding/IPT clinical algorithm. METHODS: Children who are HIV infected and attending Nsambya Home Care at Nsambya Hospital, Uganda, were screened for TB following WHO recommendations. IPT was given for 6 months after excluding TB. Factors associated with time to IPT initiation were investigated by multivariate Cox proportional hazard regression. Health care workers were interviewed on reasons for delay in IPT initiation. RESULTS: Among the 899 (49% male) children with HIV, 529 (58.8%) were screened for TB from January 2011 to February 2013. Children with active TB were 36/529 (6.8%), 24 (4.5%) were lost to follow-ups and 280 (52.9%) started IPT, 86/280 (30.7%) within 3 months of TB screening and 194/280 (69.3%) thereafter. Among the 529 children screened for TB, longer time to IPT initiation was independently associated with cough at TB screening (hazard ratio 0.62, P = 0.02, 95% confidence interval: 0.41 to 0.94). Four children (1% of those starting treatments) interrupted IPT because of a 5-fold increase in liver function measurements. In the survey, Health care workers reported poor adherence to antiretroviral therapy, poor attendance to periodic HIV follow-ups, and pill burden as the 3 main reasons to delay IPT. CONCLUSION: In resource-constrained settings, considerable delays in IPT initiation may occur, particularly in children with HIV who are presenting with cough at TB screening. The good safety profile of isoniazid in antiretroviral-therapy-experienced children provides further support to IPT implementation in this population.
[New York, New York], United Nations General Assembly, 2016 Apr 1.  p. (A/70/811)This new report warns that the AIDS epidemic could be prolonged indefinitely if urgent action is not implemented within the next five years. The report reveals that the extraordinary acceleration of progress made over the past 15 years could be lost and urges all partners to concentrate their efforts to increase and front-load investments to ensure that the global AIDS epidemic is ended as a public health threat by 2030. The review of progress looks at the gains made, particularly since the 2011 United Nations Political Declaration on HIV and AIDS, which accelerated action by uniting the world around a set of ambitious targets for 2015. The report outlines that the rapid treatment scale-up has been a major contributing factor to the 42% decline in AIDS-related deaths since the peak in 2004 and notes that this has caused life expectancy in the countries most affected by HIV to rise sharply in recent years. The report underlines the critical role civil society has played in securing many of the gains made and the leadership provided by people living with HIV. Community efforts have been key to removing many of the obstacles faced in scaling up the AIDS response, including reaching people at risk of HIV infection with HIV services, helping people to adhere to treatment and reinforcing other essential health services.