Monday, November 15, 2010

HIV Treatment: A powerful tool for prevention

Over a decade ago, Kenya was grappling with the HIV and AIDS epidemic. In 1999, the then president Daniel Moi declared this disease a national disaster. However, with the introduction of antiretroviral therapy (ART) in 2003, tremendous achievements have been made in containing the impact of HIV.

Since then, the HIV prevalence rate in Kenya seems to have decreased and stabilized at about 7.4 percent. That notwithstanding, new HIV infections are still high. According to the Kenya National Strategic Plan 2009/10- 2012/2013, Kenya records an estimated 166,000 new HIV infections annually, translating to 455 new infections daily. This is against the backdrop of the already 1.4 million Kenyans who are living with the virus.

While HIV continues to be a crisis in Kenya, there is new hope to further decrease HIV-related death and HIV transmission. New studies show that ART dramatically reduces sexual transmission of HIV. In order to fully realize the benefit of using antiretroviral medication as HIV prevention, testing and treatment must be scaled up to reach significantly higher numbers of Kenyans affected by the virus. This scale up will require additional funds from donors and the Government of Kenya alike.

Currently, only 38 to 45 percent of those in need of treatment are being reached. The coverage for children is much lower, at about 15 percent. Up to 300,000 people living with HIV (PLHIV) are still at the risk of dying, simply because of lack of access to treatment.

According to a recent article in The Lancet, a medical journal, ART reduces plasma HIV-1 concentrations to undetectable concentrations within six months on initiation. Seminal and cervicovaginal HIV-1 concentrations are also reduced to undetectable levels in most patients on ART.

The study – a prospective cohort study – conducted in Southern and East Africa included 3381 sero-discordant couples. Out of this, there was only one HIV-1 transmission event with ART use – a 92 percent reduction in transmission! The study also indicates that risky sexual behaviour reduced after ART was initiated.

This shows strong evidence that ART is both a treatment and extremely effective prevention exercise. It is probably the most effective prevention tool at our disposal now. Newer, less toxic ART makes the risk-benefit ratio to weigh in favour of treating at higher CD4, both for the individual patient as well as for population-level prevention.

Kenya can lead the way with bold new initiatives to use treatment as prevention and make Kenya a low transmission-zone for HIV. This will require increased commitments for funding and resources from government and donors alike.

Initial expansions could include ensuring rapid and universal adoption of Kenya’s new HIV treatment guidelines that provide for initiation with tenofovir-based regimens at CD4 counts of 350 as well as treatment for all TB co-infected patients. Additionally, programmatic and funding support is needed to achieve the goal of universal opt-out testing for all Kenyans 14-65 years old by 2013.

Additional potential interventions can include testing for viral load and initiating treatment for all those with HIV viral loads of over 50,000, regardless of the CD4 count. It has been established that a commitment to purchase enough tests for every PLWHIV in Kenya would quickly half the per-test cost, to less than $15(Shs1140) per test.

Of course, there continue to be major issues to address so that HIV treatment scale up can be successful. A reliable and consistent supply of ARVs is crucial as is strengthening human resources for health workers and ensuring clinicians providing ARV care are appropriately trained.

Further, increased numbers of patients on ARVs may foreseeably put pressure on the overall health system. In order to mitigate this potential roadblock, HIV treatment guidelines should consider monitoring simplification including providing a longer time between appointments for patients who are stable and doing well.

It is crucial that Kenya actively increase sustainable funding for HIV. Almost 70% of funding for HIV in Kenya is provided by external donors. Kenya must utilize donor money wisely and work with donors such as the Global Fund and PEPFAR to negotiate increased commitments for treatment as prevention programs.

However, there are also signs that government commitments are growing. This year, the government allocated 900 million to ARVs. This is almost double last year’s budget allocation to the same, there is still more that needs to be done. Kenya must also continue to pursue innovative financing measures such as looking towards the NHIF for outpatient HIV care and investigating airline taxes as ways to fund ARVs.

So far, vaccines pose a distant hope in HIV prevention. Vaginal microbicides have been ineffective, and treatment of sexually transmitted diseases does not reduce HIV transmission in most settings. Only condoms, abstinence, or delaying onset of sexual activity are effective. But with current patterns of behavior, none of these reduce risks sufficiently to halt the pandemic in sub-Saharan Africa, besides all this, increasing ARV coverage may just be one of the key solutions needing attention.

1 comment:

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