HIV Treatment as Prevention: Optimising the Impact of Expanded HIV Treatment Programmes
TL;DR: In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.
Abstract: Until now, decisions about how to allocate ART have largely been based on maximising the therapeutic benefit of ART for patients. Since the results of the HPTN 052 study showed efficacy of antiretroviral therapy (ART) in preventing HIV transmission, there has been increased interest in the benefits of ART not only as treatment, but also in prevention. Resources for expanding ART in the short term may be limited, so the question is how to generate the most prevention benefit from realistic potential increases in the availability of ART. Although not a formal systematic review, here we review different ways in which access to ART could be expanded by prioritising access to particular groups based on clinical or behavioural factors. For each group we consider (i) the clinical and epidemiological benefits, (ii) the potential feasibility, acceptability, and equity, and (iii) the affordability and cost-effectiveness of prioritising ART access for that group. In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.
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TL;DR: It is suggested that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings.
Abstract: Purpose
We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally.
124 citations
Cites background from "HIV Treatment as Prevention: Optimi..."
...To date, this is the first study to systematically review and quantify the ART cascade among FSWs globally, which builds on a limited review already undertaken by the authors [15]....
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...transmitting HIV [15,17], it is crucial to understand the extent to which FSWs currently access ART, and continue ART with good adherence....
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...Ensuring high levels of ART uptake, adherence and retention among FSWs, would provide not only individual benefits to HIV-infected FSWs, but could also help reduce HIV transmission at the population level [15,16]....
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TL;DR: Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.
Abstract: Although disproportionately affected by HIV, sex workers (SWs) remain neglected by efforts to expand access to antiretroviral treatment (ART). In Zimbabwe, despite the existence of well-attended services targeted to female SWs, fewer than half of women diagnosed with HIV took up referrals for assessment and ART initiation; just 14% attended more than one appointment. We conducted a qualitative study to explore the reasons for non-attendance and the high rate of attrition. Three focus group discussions (FGD) were conducted in Harare with HIV-positive SWs referred from the ‘Sisters with a Voice’ programme to a public HIV clinic for ART eligibility screening and enrolment. Focus groups explored SWs’ experiences and perceptions of seeking care, with a focus on how managing HIV interacted with challenges specific to being a sex worker. FGD transcripts were analyzed by identifying emerging and recurring themes that were specifically related to interactions with health services and how these affected decision-making around HIV treatment uptake and retention in care. SWs emphasised supply-side barriers, such as being demeaned and humiliated by health workers, reflecting broader social stigma surrounding their work. Sex workers were particularly sensitive to being identified and belittled within the health care environment. Demand-side barriers also featured, including competing time commitments and costs of transport and some treatment, reflecting SWs’ marginalised socio-economic position. Improving treatment access for SWs is critical for their own health, programme equity, and public health benefit. Programmes working to reduce SW attrition from HIV care need to proactively address the quality and environment of public services. Sensitising health workers through specialised training, refining referral systems from sex-worker friendly clinics into the national system, and providing opportunities for SW to collectively organise for improved treatment and rights might help alleviate the barriers to treatment initiation and attention currently faced by SW.
100 citations
Cites background from "HIV Treatment as Prevention: Optimi..."
...At the same time, the “Universal Access” agenda has made equity a guiding principle for national programmes, leading to greater prioritisation of key populations, including sex workers [10,11]....
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TL;DR: Migration and globalization has contributed to the spread of non-B subtypes contributing to 20–60% of new infections in Europe, Asia and America.
Abstract: In 30 years, the HIV-1/AIDS pandemic has evolved into an increasingly complex disease composed of multiple epidemics, each influenced by a complex array of biological, behavioural and cultural factors [1–4]. The concentrated subtype B epidemics in Western world settings have been largely restricted to MSM and IDU populations [3]. The generalized heterosexual (HET) epidemics in Africa and Asia have expanded and diversified to include nine major HIV-1 subtypes (A–D, F–H, J and K) and mosaic circulating recombinant forms (e.g. CRF01_AE and CRF02_AG) [1,5,6]. Migration and globalization has contributed to the spread of non-B subtypes contributing to 20–60% of new infections in Europe, Asia and America [1,2,7].
83 citations
TL;DR: It is hoped that the principles described here will become a shared resource that facilitates constructive discussions about the policy implications that emerge from HIV epidemiology modelling results, and that promotes joint understanding about when modelling is useful as a tool in quantifying HIV epidemiological outcomes and improving prevention programming.
Abstract: Public health responses to HIV epidemics have long relied on epidemiological modelling analyses to help prospectively project and retrospectively estimate the impact, cost-effectiveness, affordability, and investment returns of interventions, and to help plan the design of evaluations. But translating model output into policy decisions and implementation on the ground is chal- lenged by the differences in background and expectations of modellers and decision-makers. As part of the PLoS Medicine Collection ''Investigating the Impact of Treat- ment on New HIV Infections''—which focuses on the contribution of modelling to current issues in HIV prevention—we present here principles of ''best practice'' for the construction, reporting, and interpretation of HIV epidemiological models for public health decision-making on all aspects of HIV. Aimed at both those who conduct modelling research and those who use modelling results, we hope that the principles described here will become a shared resource that facilitates constructive discussions about the policy implications that emerge from HIV epidemiology modelling results, and that promotes joint understanding between modellers and decision-makers about when modelling is useful as a tool in quantifying HIV epidemiological outcomes and improving prevention programming.
83 citations
Cites background from "HIV Treatment as Prevention: Optimi..."
...[19], or prioritised for treatment as prevention [20])....
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TL;DR: “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use.
Abstract: HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.
78 citations
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53 citations
TL;DR: There is a critical need to improve patient–provider communication about the importance of ART adherence and its benefits for patient’s health.
Abstract: Background: Little is known about patients' health literacy regarding antiretroviral therapy (ART) adherence and drug resistance and patient–provider communication about these topics. Design and Me...
53 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
.... Affordability and feasibility are negatively affected not only by larger group size, but also by the more intensive efforts required to identify eligible people and maintain high adherence and retention in care. Globally, patients' health literacy regarding ART adherence remains an important challenge...
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TL;DR: If HIV-infected individuals maintaining high levels of plasma HIV-1 RNA for extended period of time contribute disproportionally to HIV transmission, a modified “test-and-treat” strategy targeting such individuals by repeated HIV testing (followed by initiation of cART) might be a useful public health strategy for mitigating the HIV epidemic in some communities.
Abstract: The first aim of the study is to assess the distribution of HIV-1 RNA levels in subtype C infection. Among 4,348 drug-naive HIV-positive individuals participating in clinical studies in Botswana, the median baseline plasma HIV-1 RNA levels differed between the general population cohorts (4.1–4.2 log10) and cART-initiating cohorts (5.1–5.3 log10) by about one log10. The proportion of individuals with high (≥50,000 (4.7 log10) copies/ml) HIV-1 RNA levels ranged from 24%–28% in the general HIV-positive population cohorts to 65%–83% in cART-initiating cohorts. The second aim is to estimate the proportion of individuals who maintain high HIV-1 RNA levels for an extended time and the duration of this period. For this analysis, we estimate the proportion of individuals who could be identified by repeated 6- vs. 12-month-interval HIV testing, as well as the potential reduction of HIV transmission time that can be achieved by testing and ARV treating. Longitudinal analysis of 42 seroconverters revealed that 33% (95% CI: 20%–50%) of individuals maintain high HIV-1 RNA levels for at least 180 days post seroconversion (p/s) and the median duration of high viral load period was 350 (269; 428) days p/s. We found that it would be possible to identify all HIV-infected individuals with viral load ≥50,000 (4.7 log10) copies/ml using repeated six-month-interval HIV testing. Assuming individuals with high viral load initiate cART after being identified, the period of high transmissibility due to high viral load can potentially be reduced by 77% (95% CI: 71%–82%). Therefore, if HIV-infected individuals maintaining high levels of plasma HIV-1 RNA for extended period of time contribute disproportionally to HIV transmission, a modified “test-and-treat” strategy targeting such individuals by repeated HIV testing (followed by initiation of cART) might be a useful public health strategy for mitigating the HIV epidemic in some communities.
52 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...How this form of prioritisation would affect the number of patients eligible for treatment is not clear: a recent analysis of HIV-1 RNA viral load data from two general population cohorts in Botswana suggested that 24%–28% and 14%–18% of HIV-infected, treatment-naı̈ve individuals (n = 1,286) had viral load levels greater than 50,000 and 100,000 copies/ml, respectively [32], but it is unclear how many of these individuals were not eligible under current CD4-based ART initiation guidelines....
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TL;DR: Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts.
Abstract: Background: Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge control efforts in resource-limited settings. We reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). This article presents syntheses of evidence on the costs, effects and cost-effectiveness of HIV MTCT strategies for LMICs from the published literature and evaluates their implications for policy and future research. Methods: Candidate studies were identified through a comprehensive database search including PubMed, Embase, Cochrane Library, and EconLit restricted by language (English or French), date (January 1st, 1994 to January 17 th , 2011) and article type (original research). Articles reporting full economic evaluations of interventions to prevent or reduce HIV MTCT were eligible for inclusion. We searched article bibliographies to identify additional studies. Two authors independently assessed eligibility and extracted data from studies retained for review. Study quality was appraised using a modified BMJ checklist for economic evaluations. Data were synthesised in narrative form. Results: We identified 19 articles published in 9 journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings as measured against accepted international benchmarks. In concentrated epidemics where HIV prevalence in the general population is very low, MTCT strategies based on universal testing of pregnant women may not compare well against cost-effectiveness benchmarks, or may satisfy formal criteria for cost-effectiveness but offer a low relative value as compared to competing interventions to improve population health. Conclusions and Recommendations: Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future costeffectiveness analyses can help to ensure that pMTCT interventions for LMICs reach their full potential by focussing on unanswered questions in four areas: local assessment of rapidly evolving HIV MTCT options; strategies to improve coverage and reach underserved populations; evaluation of a more comprehensive set of MTCT approaches including primary HIV prevention and reproductive counselling; integration of HIV MTCT and other sexual and reproductive health services.
49 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...Costeffectiveness studies of ART in pregnant women have thus far focused on benefits in terms of PMTCT, and have found that it is cost-effective as measured against accepted international benchmarks in a variety of low- and middle-income countries [53,54]....
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TL;DR: Clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
Abstract: Concerns have been raised that marginalised populations may not achieve adequate compliance to antiretroviral therapy. Our objective was to describe the long-term virological, immunological and mortality outcomes of providing highly active antiretroviral therapy (HAART) with strong adherence support to HIV-infected female sex workers (FSWs) in Burkina Faso and contrast outcomes with those obtained in a cohort of regular HIV-infected women. Prospective study of FSWs and non-FSWs initiated on HAART between August 2004 and October 2007. Patients were followed monthly for drug adherence (interview and pill count), and at 6-monthly intervals for monitoring CD4 counts and HIV-1 plasma viral loads (PVLs) and clinical events. 95 women, including 47 FSWs, were followed for a median of 32 months (interquartile range [IQR], 20-41). At HAART initiation, the median CD4 count was 147 cells/μl (IQR, 79-183) and 144 cells/μl (100-197), and the mean PVLs were 4.94 log10copies/ml (95% confidence interval [CI], 4.70-5.18) and 5.15 log10 copies/ml (4.97-5.33), in FSWs and non-FSWs, respectively. Four FSWs died during follow-up (mortality rate: 1.7 per 100 person-years) and none among other women. At 36 months, the median CD4 count increase was 230 cells/μl (IQR, 90-400) in FSWs vs. 284 cells/μl (193-420) in non-FSWs; PVL was undetectable in 81.8% (95% CI, 59.7-94.8) of FSWs vs. 100% (83.9-100) of non-FSWs; and high adherence to HAART (> 95% pills taken) was reported by 83.3% (95% CI, 67.2-93.6), 92.1% (95% CI, 78.6-98.3), and 100% (95% CI, 54.1-100) of FSWs at 6, 12, and 36 months after HAART initiation, respectively, with no statistical difference compared to the pattern observed among non-FSWs. Clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
49 citations
"HIV Treatment as Prevention: Optimi..." refers background in this paper
...This is likely to translate into smaller reductions in infectivity, and greater morbidity or mortality [93,107,108], and indicates that there would be a particular need for retention efforts and adherence counselling for this prioritisa-...
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...Emerging data on ART provision amongst FSWs [92,93,95,107] suggest that FSWs can be successfully initiated on ART in resource-poor settings; existing interventions could act as an easy...
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...and affordable entry point for increasing ART coverage among FSWs [93]....
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