Zero infections is not a pipe-dream

01 Nov, 2015 - 00:11 0 Views
Zero infections is not  a pipe-dream Adherence generally has not been very impressive. In South Africa, which has the largest ART programme in the world, one study found that only 64 percent of people who were initiated on treatment between 2002 and 2007 were still in care three years on

The Sunday Mail

Dr Sebastian Ndlovu
The UN reports that in the past 15 years, the number of people newly infected by HIV each year has dropped from 3,1 million to two million.
However, Aids is still the leading cause of death among adolescents in Sub-Saharan Africa, and 22 million people living with HIV are not accessing life-saving anti-retroviral therapy. New HIV infections continue to rise in some locations and in populations that are typically excluded or marginalised.
Sustainable Development Goal 3 aspires to ensure health and well-being for all, including a bold commitment to end the epidemics of Aids, TB, malaria and other communicable diseases by 2030. It also aims to achieve universal health coverage, and provide access to safe and effective medicines and vaccines for all.
It will be a great challenge to put measures to stem the HIV epidemic in just 15 years, but, however, it can be achieved with the right policies in place.
Against this background the World Health Organisation recently updated the HIV/Aids guidelines for treatment and prevention.
However, WHO guidelines are not routinely assimilated into our own guidelines because of resource constraints. It will be interesting see how the local policy-makers will try and assimilate the latest guidelines because the evidence they are based on is almost immutable.

Adherence generally has not been very impressive. In South Africa, which has the largest ART programme in the world, one study found that only 64 percent of people who were initiated on treatment between 2002 and 2007 were still in care three years on

Adherence generally has not been very impressive. In South Africa, which has the largest ART programme in the world, one study found that only 64 percent of people who were initiated on treatment between 2002 and 2007 were still in care three years on

Test and Treat Strategy
HIV/Aids testing has always been controversial and unpopular chiefly maybe because it is one infection where after being diagnosed, treatment is withheld until the patient becomes “sicker”.
That leads to a lot of distress and some people who are seemingly well before testing may deteriorate fast after getting to know their positive status. Probably due to depression leading to poor eating habits, self-neglect and so on.
But it does not have to be so anymore. HIV infection should be viewed as any other disease and treated regardless of the stage.
The practice of testing and treating has been adopted informed by recent findings from clinical trials confirming that early use of ART keeps people living with HIV alive, healthier and reduces the risk of transmitting the virus to partners.
A few years ago a study from South Africa estimated that the implementation of universal voluntary HIV testing in South Africa for adults over 15 years old would decrease HIV prevalence to one percent within 50 years, quite an ambitious model I should say.
Treatment as prevention (TasP) refers to HIV prevention methods that use anti-retroviral treatment (ART) to decrease the risk of HIV transmission.
ART reduces the HIV viral load in the blood, semen, vaginal fluid and rectal fluid to very low levels (“undetectable”), reducing an individual’s risk of HIV transmission. In simple terms, putting someone on treatment reduces the amount of infectious HIV particles that are circulating or replicating within the body.
Within a few months on treatment, the viral load is undetectable, rendering the person almost non-infectious.
Studies done in sero-discordant couples, that is people living together whereby one partner is positive and the other is negative, showed that treatment of the positive partner with ART reduced HIV transmission to the negative partner by as much as 96 percent, effectively matching the use of a condom.
Hence in 2013, WHO recommended that anti-retroviral treatment be offered to all people living with HIV who have uninfected partners to reduce HIV transmission.
Treating each and every individual with HIV infection is now very possible because the drugs developed recently have less side-effects and are better tolerated than the drugs of yester-year. The “treat-all” initiative, however, will not come without any challenges, chief of them being the cost.
It is estimated that the number of people eligible for anti-retroviral treatment will increase from 28 million to all 37 million people who currently live with HIV globally if this recommendation is put to practice.
Zimbabwe has about 1,4 million people infected with HIV, and the treatment programme only covers about 900 000 patients currently, meaning an addition 500 000 people will need to be initiated on treatment. This practice demands the use of drugs with low side-effect profiles, which are currently over-priced.
For instance, in the US, the combination drug that is currently preferred as first line treatment is called Triumeq.
The fixed dose combination equivalent of that drug is currently not available in Zimbabwe. However, the cost of a month’s supply of individual drugs that make up Triumeq will amount to about US$150, whilst the more common Tenolam-E costs about US$20 per month.
This translates to either US$2,5 billion per year for Triumeq or US$336 million if Tenolam-E is used. The former will amount to more than half the national budget for 2015!
For the ARVs to be effective in maintaining an undetectable viral load, adherence to the treatment should be over 95 percent. This means that the patient should virtually not miss any dose. This has been made possible by the formulating drugs that can be taken just once per day.
Adherence generally has not been very impressive. In South Africa, which has the largest ART programme in the world, one study found that only 64 percent of people who were initiated on treatment between 2002 and 2007 were still in care three years on.
Some have argued that treating a positive “well” person could lead to less adherence, because the person believes that they are not sick.
Poor adherence would lead to more drug resistance. One study from LA County, USA, reported that the use of “test and treat” among men who have sex with men could almost double the prevalence of multi-drug resistant HIV cases from 4,8 percent to 9,1 percent by 2023 among this group.
Bigger challenges and questions remain around the implementation of TasP in resource-limited settings like Zimbabwe.
The supply of ARVs in Zimbabwe has been reported to be erratic at times due to breakdowns in drug delivery systems. Patients have had incidences of being switched to different regimens, which encourages drug resistance. If the resources are stressed by treating all HIV-positive people the problem could be compounded.
Indeed, its success depends much upon the ability of a country’s healthcare service to deliver these services. The burden of adding treatment-based prevention to already strained healthcare systems remains unknown but could be calamitous.
Ethical and public health concerns have also been raised about how limited supplies of anti-retroviral drugs in resource-poor countries are distributed – for treatment, prevention or both. One study concludes it is “unethical to watch patients with treatable Aids worsen and die, even with supportive care, so that medications for treatment can be diverted for prevention”.
However, others maintain that while TasP requires large financial investments and poses significant implementation challenges, it is potentially a highly cost-effective approach to reducing both new HIV infections and the overall global HIV burden.
It is evident that TasP has a lot of potential in reducing population level rates of HIV transmission by increasing uptake of HIV testing, offering ART and linking people to care. In order to be effective, TasP needs to be delivered as part of a comprehensive package of prevention methods including HIV and Aids education, sexual and reproductive health education, condom use and behaviour change.
90-90-90 Strategy
Expanding access to treatment is at the heart of a new set of targets for 2020 with the aim to end the Aids epidemic by 2030. These targets include 90 percent of people living with HIV being aware of their HIV infection, 90 percent of those receiving anti-retroviral treatment, and 90 percent of people on ART having no detectable virus in their blood.
These are very ambitious targets, for instance in Zimbabwe according to the latest ZimStat reports, the percentage of people aged 15-49 years who have been tested for HIV in the last 12 months and who know their results is 50,6 percent for women and 40,3 percent for men. This is way below the 90 percent target by 2020 set by UNAids.
However, the Ministry of Health and Child Care has since embarked on a national door-to-door HIV and Aids survey to assess the state of the pandemic in Zimbabwe.
The survey, known as Zimbabwe Population-Based HIV Impact Assessment, targets 15 000 households countrywide.
The survey, apart from measuring the prevalence rate of HIV in the country, will provide testing for HIV and syphilis, CD4 count testing for those living with HIV, direct counselling, treatment and referral care for people who may test positive for HIV.
According to UNAids estimates, expanding ART to all people living with HIV and expanding prevention choices can help avert 21 million Aids-related deaths and 28 million new infections by 2030.
This will ensure that having an Aids-free generation is not a pipedream but a reality.

Dr Sebastian Ndlovu is a qualified medical doctor. He writes in his personal capacity and opinions expressed here are his personal opinions to create public discourse on health matters, and thereby improve public health policies

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