The future of antiretroviral treatment

A series of articles by guest writers for World AIDS Day Part of AVERT's World AIDS Day 2012 campaign, ‘Reflections on the Epidemic’ are a series of articles by guest writers. Our guest writers range from global leaders, writers, experts, activists, physicians and people personally affected by HIV and AIDS; and they represent various countries, experiences and backgrounds from all over the world. We are grateful to all our guest writers for their effort and the diverse and insightful viewpoints that they contributed to the world’s response to HIV and AIDS. We will be re-featuring these articles over the next few weeks on a weekly basis. Browse through this week’s featured articles, and see the full list below.

The world is at a significant moment in the global response to AIDS.  We now know for sure that ARVs not only keep people alive and healthy, but they also prevent them from becoming infected. What seemed unthinkable 10 years ago has become reality: 8 million people have access to antiretroviral treatment (ART) in low- and middle-income countries. How optimistic can and should we be for the future? Is it possible and likely that the target of 15 million in 2015 will be reached? Or, to be even more aspirational, can we stop people from becoming infected altogether, or in other words, end the epidemic?

Let us have a closer look at what that would entail. One key challenge facing the global community is to determine how ARVs can be most strategically and effectively used for greatest impact on lives and new infections. This involves balancing greater complexity and more choices with the need to use limited resources most wisely.

With new evidence, more people will require and rightly demand access to ARVs.  Already today, consistent with the current WHO recommendations (CD4 with 350 cells/mm³ or below) around 15 million people are eligible.  WHO estimates that incrementally adding “treatment as prevention” for HIV serodiscordant couples, pregnant women, and key affected populations would increase the number of people in need of ART to around 23 million people in low- and middle-income countries. Ultimately, sooner or later, everybody who is HIV positive, currently 34 million people, will need ARVs.

To reach more people with better services, free of stigma and exclusion, we need to be both more innovative and more effective in providing ART. The significant potential for innovation is captured in the Treatment 2.0 agenda for action. This includes a range of strategies to optimize ART regimens, realize the promise of point-of-care diagnostics, reduce costs, and better integrate ART into other health services.  

This also means plugging “leaks” in the continuum of care from testing to ultimately ensuring viral suppression. On a population basis, increasing uptake of testing requires a mix of methods from facility-based and community-based HIV testing services. Even self-testing is a method that is currently being explored in resource-limited settings. Whoever tests positive needs to be appropriately linked to treatment and care, and needs support to adhere to therapy.

One of WHO’s roles is to provide up-to-date guidance to countries about the range of strategies for using ART most effectively. For example, in 2012, WHO released updates on treatment as prevention and PMTCT, and a guideline on testing and treatment of serodiscordant couples. 

Currently, WHO is working on consolidated guidelines on all aspects of ART use for treatment and prevention, for all age groups and populations. This document will also include programmatic guidance to countries on how to scale up programmes most equitably and with full consideration of ethical and human rights issues.

Future progress in scaling up ART will depend on how effectively and strategically countries can respond to emerging scientific evidence and new guidance, and on how they prioritize their approaches to expand the reach and effectiveness of ART programmes. Given the recent pace of scale up and opportunities for enhancing the service cascade, I am optimistic that the 15 million target can and will be reached, and that we can bring the treatment and prevention benefits of ARVs to millions more beyond 2015.

Dr Gottfried Hirnschall, MD, MPH is Director of the Department of HIV/AIDS at the World Health Organization in Geneva, Switzerland.

For further information on the global epidemic see AVERT's section.

Images:'People being tested for HIV', copyright Mike Blyth. 'Gottfried Hirnschall', copyright: WHO