Wider access to antiretroviral therapy, but greater scale-up urgently needed

A new WHO report reveals that 199 000 people in the 22 low- and middle-income countries in the WHO European Region received antiretroviral therapy (ART) in 2012: 45% more than in 2011. Access to ART expanded substantially in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Lithuania, the Republic of Moldova, the Russian Federation, Tajikistan, Turkey, Ukraine and Uzbekistan.

Nevertheless, the Region’s efforts to scale up access to ART are not keeping pace with the annual increases in the number of people acquiring HIV infection. The HIV burden in the Region is particularly large among people who inject drugs, sex workers and men who have sex with men, but these key populations appear to have less access to ART than the wider population.

On 30 June 2013, WHO released the “Global update on HIV treatment 2013” and new consolidated guidelines on the use of ART at the 7th IAS [International AIDS Society] Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur, Malaysia. Both reports underscore the need to intensify efforts to expand access to ART.

Global access to ART

“Global update on HIV treatment 2013” charts the progress being made in scaling up the use of ART in low- and middle-income countries, the challenges that need to be or are being overcome, and the opportunities for building on the achievements of the past decade.

Globally, close to 10 million people in low- and middle-income countries were receiving ART in 2012 (an increase of 1.6 million from 2011), marking the largest annual increase ever witnessed in this area. Unfortunately, the WHO European and Eastern Mediterranean regions still have the lowest estimated treatment coverage in low- and middle-income countries. Low access to ART for key populations, low coverage of opioid substitution therapy and lack of integrated services for HIV, TB and drug use are considered the main barriers to HIV treatment and care.

New guidelines on ART

WHO’s “Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection” aims to translate new evidence and country experiences into clinical, operational and programmatic guidance that can transform the way in which countries use these drugs and enable them to achieve universal-access targets, as well as universal health coverage, efficiently and sustainably. WHO raised the CD4 threshold for starting treatment of HIV-positive adults and adolescents from 350 cells/mm3 (as recommended by WHO in 2010) to 500 cells/mm3.

Recent evidence indicates that earlier ART will help people with HIV to live longer, healthier lives, and substantially reduce their risk of transmitting HIV to others. This could avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025.

Treatment regardless of CD4 count is recommended for all HIV-positive children below the age of 5 years, HIV-positive pregnant women, people co-infected with HIV and TB or hepatitis B, and HIV-positive partners in relationships with people who do not have HIV.

In contrast to the 2010 guidelines, the 2013 guidelines:

  1. call for offering treatment to people with HIV before its begins to damage their immune systems (CD4 threshold: 500 cell/mm3), and offering less toxic drugs, simpler treatment formulations, and closer monitoring of treatment;
  2. harmonize all adult treatment regimens into one preferred first-line therapy and recommend the initial drugs for everyone; and
  3. simplify and improve service delivery.

The new recommendations increase the potential number of people eligible for ART globally to an estimated 25.9 million in 2013: 9.2 million more than under the 2010 guidelines