By DANN OKOTH

Governments are making improvements to get better antiretroviral treatment (ART) to more people, a study released on Thursday at the International Aids Conference in Washington DC says.

And the conference concluded with a strong message that the tide against Aids can be turned.

The study ‘Speed up scale-up’ presenting policy dashboard and report closer to home’ released by Doctors Without Borders or Médecins Sans Frontières (MSF) maps progress across 23 countries on HIV treatment strategies, tools, and policies needed to increase treatment scale-up.

“The results show that governments have made improvements to get better antiretroviral treatment (ART) to more people, but implementation of innovative community-based strategies is lagging in some countries,” notes the study, done in collaboration with UNAids.

The study looked at 25 indicators in each country, ranging from coverage of ART and prevention of mother-to-child transmission (PMTCT), to whether nurses, instead of doctors, can start patients on HIV and TB treatment – critical to relieving the burden on health systems and to getting treatment further into communities – and how many health facilities in each country offer ART.

Better medicine

“What we’re seeing is that governments are working to get better HIV medicines to their people, and to provide treatment closer to home so that more people can benefit,” said Sharonann Lynch, HIV Policy Advisor for MSF’s Access Campaign, who headed the research.

“But there’s still a long way to go. More countries need to shift policies to allow nurses to start people on treatment, and other health workers to monitor patients’ treatment so treatment can be available in every clinic, in every village, and in every country struggling with HIV.”

The study found that 11 of 23 countries have reached ART coverage of 60 per cent or more, while six are still reaching only one third of people in need.

Six countries have PMTCT coverage rates over 80 per cent while eight are still below 50 per cent, with five of these below 30 per cent. Only eight of the 20 countries for which data was available provide ART in 30 per cent or more of their health facilities, while in countries like Lesotho, Malawi and South Africa where over 60 per cent of health facilities offer ART, treatment coverage is greater, at more than 50 per cent. Of the 18 sub-Saharan African countries in the study, 11 allow nurses to start patients on ART, with Kenya, South Africa, Swaziland, Uganda, Zambia and Zimbabwe having changed their policies just in the last two years to allow this.

Mozambique is the country with the highest HIV prevalence of the countries in the study to still not allow basic nurses to initiate and manage ART.

It is estimated Kenya has 1.5 million people living with HIV. Only 500,000 are already receiving life-sustaining HIV treatment. Treatment coverage is even lower for children, currently standing at a mere 34 per cent of those in need.

Further, all countries in the survey had adopted WHO-recommended better-tolerated ARVs, and ART initiation at 350 CD4 cell count, although implementation in some countries lag due to funding shortfalls. Of 23 countries surveyed, only four have access to viral load monitoring.

“One of the biggest questions being posed at this conference is whether it will be feasible to reach the number of people in need of treatment in order to start reversing the epidemic,” said Dr Tom Decroo of MSF in Mozambique.

“There’s a lot of talk about efficiencies at this conference, but we have to make sure the patient doesn’t get lost in this discussion. Moving treatment down to the community level means the interest of patients and health systems overlap.

“We’re showing that we can take HIV care out of hospitals and keep people healthy while making life easier for patients and easing the strain on the health system. We’re starting to move toward a model of patient care similar to that of chronic disease management in developed countries.”

Better tools to get ahead of the wave of new infections are equally critical, the study noted. All countries in the survey have shifted policies to provide better-tolerated ARVs to people – although implementation can depend on availability of funding.

But only four of the countries in the survey have access to viral load testing, which is the gold standard in treatment monitoring and routine in developed countries.

Meanwhile participants at the IAC, whose declaration is to end the Aids epidemic by ‘turning the tide together’, emerged with an overriding message that: “We can turn the tide and end Aids.”

There were many speakers reinforcing the robustness of treatment as prevention and particularly emphasising that increased up-front investment now on the part of donors and implementing countries can lead to relatively rapid declines in new infections, resulting in an overall decreased HIV burden and decreased funding requirement.

Many civil society groups held a large demonstration (involving about 10,000 people) called We Can End Aids. There were five marches that all converged on the White House. Each march had a different theme, but all demanding sufficient resources and policies to end Aids.

Deliberations at the conference also focused on HIV diagnostics with point of care tests being a hot topic.

Point of care CD4 tests are being used more and more in the field including in low and middle-income countries. Studies have shown that point of care tests can decrease the time a patient waits until they get on HIV therapy and also increase the amount of patients who stay in care.

Discussions, our sources in Washington revealed, also revolved around how viral load is a key tool that low and middle-income countries should start using.

Treatment failure

“Viral load can help identify treatment failure sooner and identify patients who may need intensive adherence counselling which can save them from having to switch from first to second line HIV therapy,” says Jennifer Cohn, Assistant Professor division of infectious Diseases at university of Pennsylvania.

Many speakers commented that for stable patients with higher CD4 counts, viral load can replace CD4 as a better measure of treatment success and thus have the potential to be more cost-efficient over a strategy that uses CD4+viral load monitoring or CD4 monitoring alone. Very few countries use viral load as routine monitoring, but some, like Malawi are beginning to use yearly viral load in their guidelines.

Other recommendations included the use of Mobile Health or ‘mHealth’ as a means to help improve patient adherence.

Cell phone text messages to help remind patients to take their medicines or to check in to see if a patient is having any problems helps improve adherence and decreases loss to follow up.

Mhealth can also be used to help better link community health workers to clinics and ensure the information they gather in the field is transmitted to treating clinicians.

Meanwhile, there has been a lot of talk about the cure.

While this is years and perhaps decades away, a lot of basic science is focusing on how to eradicate virus that is latent (resting) in cells even when a patient’s viral load is undetectable.

Participants noted that no cure has been found yet, but observed that the science is beginning to bring us a little closer.

The issue of adherence and retention in care came up at the conference with speaker after speaker marinating that there is need to find better ways to make sure patients stay in care.

It is estimated that up to 50 per cent of patients who test HIV positive in several countries in Africa never show up to the clinic for treatment and care.

Strategies including point of care CD4 count, earlier treatment initiation, mHealth reminders and immediate linkage to care can help both retain more patients in care and also lead to better clinical outcomes (less patient deaths).

But there is still need for better tools and systems to improve the rates of linkage to and retention in care.