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Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines.
AIDS Care. 2017 Dec; 29(12):1473-1479.New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (>/=98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.
Application opportunities of geographic information systems analysis to support achievement of the UNAIDS 90-90-90 targets in South Africa.
South African Medical Journal. 2017 Nov 27; 107(12):1065-1071.In an effort to achieve control of the HIV epidemic, 90-90-90 targets have been proposed whereby 90% of the HIV-infected population should know their status, 90% of those diagnosed should be receiving antiretroviral therapy, and 90% of those on treatment should be virologically suppressed. In this article we present approaches for using relatively simple geographic information systems (GIS) analyses of routinely available data to support HIV programme management towards achieving the 90-90-90 targets, with a focus on South Africa (SA) and other high-prevalence settings in low- and middle-income countries. We present programme-level GIS applications to map aggregated health data and individual-level applications to track distinct patients. We illustrate these applications using data from City of Johannesburg Region D, demonstrating that GIS has great potential to guide HIV programme operations and assist in achieving the 90-90-90 targets in SA.
The continuum of HIV care in South Africa: implications for achieving the second and third UNAIDS 90-90-90 targets.
AIDS. 2017 Feb 20; 31(4):545-552.BACKGROUND: We characterize engagement with HIV care in South Africa in 2012 to identify areas for improvement towards achieving global 90-90-90 targets. METHODS: Over 3.9 million CD4 cell count and 2.7 million viral load measurements reported in 2012 in the public sector were extracted from the national laboratory electronic database. The number of persons living with HIV (PLHIV), number and proportion in HIV care, on antiretroviral therapy (ART) and with viral suppression (viral load <400 copies/ml) were estimated and stratified by sex and age group. Modified Poisson regression approach was used to examine associations between sex, age group and viral suppression among persons on ART. RESULTS: We estimate that among 6511 000 PLHIV in South Africa in 2012, 3300 000 individuals (50.7%) accessed care and 32.9% received ART. Although viral suppression was 73.7% among the treated population in 2012, the overall percentage of persons with viral suppression among all PLHIV was 23.8%. Linkage to HIV care was lower among men (38.5%) than among women (57.2%). Overall, 47.1% of those aged 0-14 years and 47.0% of those aged 15-49 years were linked to care compared with 56.2% among those aged above 50 years. CONCLUSION: Around a quarter of all PLHIV have achieved viral suppression in South Africa. Men and younger persons have poorer linkage to HIV care. Expanding HIV testing, strengthening prompt linkage to care and further expansion of ART are needed for South Africa to reach the 90-90-90 target. Focus on these areas will reduce the transmission of new HIV infections and mortality in the general population.
South African Medical Journal. 2017 Nov 27; 107(12):1058-1064.Background. Many people living with HIV in South Africa (SA) are not aware of their seropositive status and are diagnosed late during the course of HIV infection. These individuals do not obtain the full benefit from available HIV care and treatment services. Objectives. To describe the prevalence of late presentation for HIV care among newly diagnosed HIV-positive individuals and evaluate sociodemographic variables associated with late presentation for HIV care in three high-burden districts of SA. Methods. We used data abstracted from records of 8 138 newly diagnosed HIV-positive individuals in 35 clinics between 1 June 2014 and 31 March 2015 to determine the prevalence of late presentation among newly diagnosed HIV-positive individuals in selected high-prevalence health districts. Individuals were categorised as ‘moderately late’, ‘very late’ or ‘extremely late’ presenters based on specified criteria. Descriptive analysis was performed to measure the prevalence of late presentation, and multivariate regression analysis was conducted to identify variables independently associated with extremely late presentation. Results. Overall, 79% of the newly diagnosed cases presented for HIV care late in the course of HIV infection (CD4+ count =500 cells/ µL and/or AIDS-defining illness in World Health Organization (WHO) stage III/IV), 19% presented moderately late (CD4+ count 351 -500 cells/µL and WHO clinical stage I or II), 27% presented very late (CD4+ count 201 - 350 cells/µL or WHO clinical stage III), and 33% presented extremely late (CD4+ count =200 cells/µL and/or WHO clinical stage IV) for HIV care. Multivariate regression analysis indicated that males, non-pregnant women, individuals aged >30 years, and those accessing care in facilities located in townships and inner cities were more likely to present late for HIV care. Conclusions. The majority of newly diagnosed HIV-positive individuals in the three high-burden districts (Gert Sibande, uThukela and City of Johannesburg) presented for HIV care late in the course of HIV infection. Interventions that encourage early presentation for HIV care should be prioritised in SA and should target males, non-pregnant women, individuals aged >30 years and those accessing care in facilities located in inner cities and urban townships.
National responses to global health targets: exploring policy transfer in the context of the UNAIDS '90-90-90' treatment targets in Ghana and Uganda.
Health Policy and Planning. 2018 Jan 1; 33(1):17-33.Global health organizations frequently set disease-specific targets with the goal of eliciting adoption at the national-level; consideration of the influence of target setting on national policies, program and health budgets is of benefit to those setting targets and those intended to respond. In 2014, the Joint United Nations Program on HIV/AIDS set ‘ambitious’ treatment targets for country adoption: 90% of HIV-positive persons should know their status; 90% of those on treatment; 90% of those achieving viral suppression. Using case studies from Ghana and Uganda, we explore how the target and its associated policy content have been adopted at the national level. That is whether adoption is in rhetoric only or supported by program, policy or budgetary changes. We review 23 (14 from Ghana, 9 from Uganda) national policy, operational and strategic documents for the HIV response and assess commitments to ‘90-90-90’. In-person semi-structured interviews were conducted with purposively sampled key informants (17 in Ghana, 20 in Uganda) involved in program-planning and resource allocation within HIV to gain insight into factors facilitating adoption of 90-90-90. Interviews were transcribed and analyzed thematically, inductively and deductively, guided by pre-existing policy theories, including Dolowitz and Marsh’s policy transfer framework to describe features of the transfer and the Global Health Advocacy and Policy Project framework to explain observations. Regardless of notable resource constraints, transfer of the 90-90-90 targets was evident beyond rhetoric with substantial shifts in policy and programme activities. In both countries, there was evidence of attempts to minimize resource constraints by seeking programme efficiencies, prioritization of program activities and devising domestic financing mechanisms; however, significant resource gaps persist. An effective health network, comprised of global and local actors, mediated the adoption and adaptation, facilitating a shift in the HIV program from ‘business as usual’ to approaches targeting geographies and populations.
Estimating the value of point-of-care HPV testing in three low- and middle-income countries: a modeling study.
BMC Cancer. 2017 Nov 25; 17(1):791.BACKGROUND: Where resources are available, the World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy. Newer technologies may facilitate a same-day screen-and-treat approach, but these testing systems are generally too expensive for widespread use in low-resource settings. METHODS: To assess the value of a hypothetical point-of-care HPV test, we used a mathematical simulation model of the natural history of HPV and data from the START-UP multi-site demonstration project to estimate the health benefits and costs associated with a shift from a 2-visit approach (requiring a return visit for treatment) to 1-visit HPV testing (i.e., screen-and-treat). We estimated the incremental net monetary benefit (INMB), which represents the maximum additional lifetime cost per woman that could be incurred for a new point-of-care HPV test to be cost-effective, depending on expected loss to follow-up between visits (LTFU) in a given setting. RESULTS: For screening three times in a lifetime at 100% coverage of the target population, when LTFU was 10%, the INMB of the 1-visit relative to the 2-visit approach was I$13 in India, I$36 in Nicaragua, and I$17 in Uganda. If LTFU was 30% or greater, the INMB values for the 1-visit approach in all countries was equivalent to or exceeded total lifetime costs associated with screening three times in a lifetime. At a LTFU level of 70%, the INMB of the 1-visit approach was I$127 in India, I$399 in Nicaragua, and I$121 in Uganda. CONCLUSIONS: These findings indicate that point-of-care technology for cervical cancer screening may be worthy of high investment if linkage to treatment can be assured, particularly in settings where LTFU is high.
Designing HIV testing algorithms based on 2015 WHO guidelines using data from six sites in sub-Saharan Africa.
Journal of Clinical Microbiology. 2017 Oct; 55(10):3006-3015.Our objective was to evaluate the performance of HIV testing algorithms based on WHO recommendations, using data from specimens collected at six HIV testing and counseling sites in sub-Saharan Africa (Conakry, Guinea; Kitgum and Arua, Uganda; Homa Bay, Kenya; Douala, Cameroon; Baraka, Democratic Republic of Congo). A total of 2,780 samples, including 1,306 HIV-positive samples, were included in the analysis. HIV testing algorithms were designed using Determine as a first test. Second and third rapid diagnostic tests (RDTs) were selected based on site-specific performance, adhering where possible to the WHO-recommended minimum requirements of 99% sensitivity and specificity. The threshold for specificity was reduced to 98% or 96% if necessary. We also simulated algorithms consisting of one RDT followed by a simple confirmatory assay. The positive predictive values (PPV) of the simulated algorithms ranged from 75.8% to 100% using strategies recommended for high-prevalence settings, 98.7% to 100% using strategies recommended for lowprevalence settings, and 98.1% to 100% using a rapid test followed by a simple confirmatory assay. Although we were able to design algorithms that met the recommended PPV of 99% in five of six sites using the applicable high-prevalence strategy, options were often very limited due to suboptimal performance of individual RDTs and to shared falsely reactive results. These results underscore the impact of the sequence of HIV tests and of shared false-reactivity data on algorithm performance. Where it is not possible to identify tests that meet WHO-recommended specifications, the low-prevalence strategy may be more suitable.
Geneva, Switzerland, UNAIDS, 2017. 8 p.HIV testing services are an essential gateway to HIV prevention, treatment, care and support services. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) endorse and encourage universal access to knowledge of HIV status. Increased access to and uptake of HIV testing is central to achieving the 90–90–90 targets1 endorsed in the 2016 United Nations Political Declaration on Ending AIDS. However, at the end of 2016, approximately 30% of people living with HIV were still unaware of their HIV status. Young people aged 15–24, adult males and people from key populations (men who have sex with men, transgender people, sex workers, people who inject drugs and people in prisons and other closed settings) often have significantly lower access to HIV testing services, are less likely to be linked to treatment and care and have lower levels of viral suppression. (excerpt)
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.
Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review.
Medicine. 2017 Oct; 96(40):e8055.BACKGROUND: To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets. METHODS: Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU). RESULTS: Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants. CONCLUSION: Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.
Geneva, Switzerland, UNAIDS, 2017. 198 p. (UNAIDS/JC2900E)Since they were launched at the 20th International AIDS Conference in Melbourne, Australia, in 2014, the 90-90-90 targets have become a central pillar of the global quest to end the AIDS epidemic. The targets reflect a fundamental shift in the world’s approach to HIV treatment, moving it away from a focus on the number of people accessing antiretroviral therapy and towards the importance of maximising viral suppression among people living with HIV. This shift was driven by greater understanding of the benefits of viral suppression -- not only does treatment protect people living with HIV from AIDS-related illness, but it also greatly lowers the risk of transmitting the virus to others.
Population-level impact of an accelerated HIV response plan to reach the UNAIDS 90-90-90 target in Cote d'Ivoire: Insights from mathematical modeling.
PLoS Medicine. 2017 Jun; 14(6):e1002321.BACKGROUND: National responses will need to be markedly accelerated to achieve the ambitious target of the Joint United Nations Programme on HIV/AIDS (UNAIDS). This target aims for 90% of HIV-positive individuals to be aware of their status, for 90% of those aware to receive antiretroviral therapy (ART), and for 90% of those on treatment to have a suppressed viral load by 2020, with each individual target reaching 95% by 2030. We aimed to estimate the impact of various treatment-as-prevention scenarios in Cote d'Ivoire, one of the countries with the highest HIV incidence in West Africa, with unmet HIV prevention and treatment needs, and where key populations are important to the broader HIV epidemic. METHODS AND FINDINGS: An age-stratified dynamic model was developed and calibrated to epidemiological and programmatic data using a Bayesian framework. The model represents sexual and vertical HIV transmission in the general population, female sex workers (FSW), and men who have sex with men (MSM). We estimated the impact of scaling up interventions to reach the UNAIDS targets, as well as the impact of 8 other scenarios, on HIV transmission in adults and children, compared to our baseline scenario that maintains 2015 rates of testing, ART initiation, ART discontinuation, treatment failure, and levels of condom use. In 2015, we estimated that 52% (95% credible intervals: 46%-58%) of HIV-positive individuals were aware of their status, 72% (57%-82%) of those aware were on ART, and 77% (74%-79%) of those on ART were virologically suppressed. Reaching the UNAIDS targets on time would avert 50% (42%-60%) of new HIV infections over 2015-2030 compared to 30% (25%-36%) if the 90-90-90 target is reached in 2025. Attaining the UNAIDS targets in FSW, their clients, and MSM (but not in the rest of the population) would avert a similar fraction of new infections (30%; 21%-39%). A 25-percentage-point drop in condom use from the 2015 levels among FSW and MSM would reduce the impact of reaching the UNAIDS targets, with 38% (26%-51%) of infections averted. The study's main limitation is that homogenous spatial coverage of interventions was assumed, and future lines of inquiry should examine how geographical prioritization could affect HIV transmission. CONCLUSIONS: Maximizing the impact of the UNAIDS targets will require rapid scale-up of interventions, particularly testing, ART initiation, and limiting ART discontinuation. Reaching clients of FSW, as well as key populations, can efficiently reduce transmission. Sustaining the high condom-use levels among key populations should remain an important prevention pillar.
Projected Uptake of New Antiretroviral (ARV) Medicines in Adults in Low- and Middle-Income Countries: A Forecast Analysis 2015-2025.
PloS One. 2016; 11(10):e0164619.With anti-retroviral treatment (ART) scale-up set to continue over the next few years it is of key importance that manufacturers and planners in low- and middle-income countries (LMICs) hardest hit by the HIV/AIDS pandemic are able to anticipate and respond to future changes to treatment regimens, generics pipeline and demand, in order to secure continued access to all ARV medicines required. We did a forecast analysis, using secondary WHO and UNAIDS data sources, to estimate the number of people living with HIV (PLHIV) and the market share and demand for a range of new and existing ARV drugs in LMICs up to 2025. UNAIDS estimates 24.7 million person-years of ART in 2020 and 28.5 million person-years of ART in 2025 (24.3 million on first-line treatment, 3.5 million on second-line treatment, and 0.6 million on third-line treatment). Our analysis showed that TAF and DTG will be major players in the ART regimen by 2025, with 8 million and 15 million patients using these ARVs respectively. However, as safety and efficacy of dolutegravir (DTG) and tenofovir alafenamide (TAF) during pregnancy and among TB/HIV co-infected patients using rifampicin is still under debate, and ART scale-up is predicted to increase considerably, there also remains a clear need for continuous supplies of existing ARVs including TDF and EFV, which 16 million and 10 million patients-respectively-are predicted to be using in 2025. It will be important to ensure that the existing capacities of generics manufacturers, which are geared towards ARVs of higher doses (such as TDF 300mg and EFV 600mg), will not be adversely impacted due to the introduction of lower dose ARVs such as TAF 25mg and DTG 50mg. With increased access to viral load testing, more patients would be using protease inhibitors containing regimens in second-line, with 1 million patients on LPV/r and 2.3 million on ATV/r by 2025. However, it will remain important to continue monitoring the evolution of ARV market in LMICs to guarantee the availability of these medicines.
Reinvigorating the AIDS response to catalyse sustainable development and United Nations reform. Report of the Secretary-General.
[New York, New York], United Nations, General Assembly, 2017 Apr 7. 25 p. (A/71/864)Bold global commitments, shared financial responsibility and a people-centred approach based on the principles of equity have yielded shared success in the AIDS response. The 90-90-90 initiative has guided a dramatic expansion of antiretroviral treatment and greatly reduced AIDS-related deaths, while also contributing to a reduction in new HIV infections. A global plan to eliminate mother-to-child transmission of HIV has more than halved the number of new HIV infections among children. The AIDS response has made an important contribution to the demographic dividend of Africa, its recent economic growth and the emerging vision of Africa as a continent of hope, promise and vast potential. Global optimism has fuelled the highest ambition within the 2030 Agenda for Sustainable Development: ending the AIDS epidemic by 2030. A fast-track response to reach this target has been agreed by the United Nations General Assembly within the 2016 Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030. Achieving our aims on AIDS is interlinked with and embedded within the broader 2030 Agenda: both are grounded in equity, human rights and a promise to leave no one behind. Hard-fought gains must not be lost. An international architecture that has stimulated leadership, provided direction, mobilized unprecedented levels of financial resources and saved millions of lives must not be taken for granted. Closing the investment gap of $7 billion per year and ensuring that financial resources are wisely used will avert tens of millions of new HIV infections and AIDS-related deaths, a return on investment that is nothing short of priceless. (Excerpts)
Uptake and performance of prevention of mother-to-child transmission and early infant diagnosis in pregnant HIV infected women and their exposed infants at seven health centres in Addis Ababa, Ethiopia.
Tropical Medicine and International Health. 2017 Jun; 22(6):765-775.Objective To assess the uptake of WHO-recommended PMTCT procedures in Ethiopia's health services. Methods Prospective observational study of HIV-positive pregnant mothers and their newborns attending PMTCT services at seven health centers in Addis Ababa. Women were recruited during antenatal care and followed-up with their newborns at delivery, day 6 and week 6 postpartum. Retention to PMCTC procedures, self-reported ART adherence, and HIV infant outcome were assessed. Turnaround times of HIV early infant diagnosis (EID) procedures were extracted from health registers. Results Of 494 women enrolled 4.9% did not complete PMTCT procedures due to active denial or loss to follow-up. HIV was first diagnosed in 223 (45.1%) and ART initiated in 321 (65.0%) women during pregnancy. ART was initiated in a median of 1.3 weeks (IQR 0-4.3) after HIV diagnosis. Poor self-reported treatment adherence was higher post-partum than during pregnancy (12.5% versus 7.0%, p=0.002), and significantly associated with divorced/separated marital status (RR 2.2, 95% CI 1.3-3.8), low family income (RR 2.1, 95% CI 1.1-4.1), low CD4-count (RR 1.7, 95% CI 1.0-3.0), and ART initiation during delivery (RR 2.5, 95% CI 1.1-5.6). Of 435 infants born alive 98.6% received nevirapine prophylaxis. The mother-to-child HIV transmission rate was 0.7% after a median of 6.7 weeks (IQR 6.4-10.4), but EID results were received for only 46.6% within 3 months of birth. Conclusion High retention in PMTCT services, triple maternal ART and high infant nevirapine prophylaxis coverage were associated with low mother-to-child HIV transmission. Declining post-partum ART adherence and challenges of EID linkage require attention.
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)
Guidelines on HIV self-testing and partner notification: Supplement to consolidated guidelines on HIV testing services.
Geneva, Switzerland, WHO, 2016 Dec. 104 p.This supplement to the consolidated guidelines on HIV testing services released in 2015 includes new recommendations and additional guidance on HIV self-testing (HIV ST) and assisted HIV partner notification services (PNS) to the following groups: general populations; pregnant and postpartum women; couples and partners; adolescents (10–19 years) and young people (15–24 years); key populations; and vulnerable populations. The supplement will support countries, program managers, health workers, and other stakeholders in achieving the United Nations (UN) 90-90-90 global HIV targets -- and specifically the first target of diagnosing 90 percent of all people with HIV. The supplement aims to: Support the implementation and scale-up of ethical, effective, acceptable, and evidence-informed approaches to HIV ST and PNS; Support the routine offer of voluntary assisted HIV PNS as part of a public health approach to delivering HIV testing services (HTS); Provide guidance on how HIV ST and assisted HIV PNS could be integrated into both community- and facility-based HTS approaches and be tailored to specific population groups; Support the introduction of HIV ST as a formal HTS intervention using quality-assured, approved products; Position HIV ST and assisted HIV PNS as HTS approaches that will contribute to closing the testing gap and achieving the UN’s 90-90-90 and 2030 global goals.
Bulletin of the World Health Organization. 2016; 94:782-784.In conclusion, WHO clinical guidelines have become increasingly evidence-based through the use of rigorous methods of synthesizing the evidence. Over the past decade, high-quality, pairwise meta-analyses have been widely used in this context, but network meta-analysis methods are increasingly important for the optimal evaluation of competing interventions. We expect that network meta-analysis will increasingly be used and adapted for developing other guidelines. (Excerpt)
Evolution of couples voluntary counseling and testing for HIV in Rwanda: From research to public health practice.
Journal of Acquired Immune Deficiency Syndromes. 2016;  p..Background: Couples’ Voluntary HIV Counseling and Testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. Methods: From 1988-1994, pregnant and post-partum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and STI rates, particularly among HIV discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were re-introduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the PMTCT program expanded to >400 clinics. In 2009 the GoR adopted joint post-test counseling procedures, and in 2010 a quarterly follow-up program was established in government clinics with training and technical assistance. An estimated 80 - 90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. Conclusion: Rwanda is the first African country to have established CVCT as standard of care in ANC. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda’s success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators and budgets. Governments, bilateral and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections. Copyright: 2016 Wolters Kluwer Health, Inc.
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, Joint United Nations Programme on HIV/AIDS, 2014 Oct. 40 p.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. The 90-90-90 UNAIDS target seeks to: 1) By 2020, 90% of all people living with HIV will know their HIV status; 2) By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 3) By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression. Key points: 1) Governments, health experts and civil society must take advantage of the next five-year window to meet the 90-90-90 target to tackle AIDS; 2) Early treatment can reduce infection rates by 90 %; 3) A paradigm shift in HIV/AIDS treatment has seen average drug prices fall from an average of US$15 000 to US$ 80; and 4) Health systems will improve as a result of investment in HIV/AIDS treatment; financing from the international community is indispensable.
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.