Treatment
What Works
Provision and Access
- Antiretroviral therapy has been successfully administered with good adherence, good patient retention, and good clinical outcomes in resource-poor settings with increased patient survival; results have been similar to those achieved in resource-rich countries.
- Early initiation of antiretroviral therapy results in improved quality of life and reduced mortality.
- Antiretroviral therapy initiated at CD4 counts between 350 and 550 can result in fewer serious HIV-1-related clinical events or death.
- Integration of HIV/AIDS services into primary care increases access to testing and treatment services.
There are promising strategies and further discussion that you can read about by clicking on the button below.
Adherence and Support
- Counseling improves adherence.
- Mobile phone text messages from health providers may improve adherence by providing patient support.
There are promising strategies and further discussion that you can read about by clicking on the button below.
Staying Healthy and Reducing Transmission
- ARV therapy can reduce (but does not eliminate) the risk of HIV transmission and is an additional prevention strategy.
- Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use.
- Providing information and skills-building support to people living with HIV can reduce unprotected sex.
There are promising strategies and further discussion that you can read about by clicking on the button below.
Treatment has transformed HIV/AIDS: in the early years of the epidemic, median survival after an AIDS diagnosis was measured in weeks to months. Now, however, HIV is a chronic, incurable illness disease requiring ongoing therapy. “In stark contrast to the early and mid-1980s, if a person aged 20 years is newly infected with HIV today and guideline-recommended therapy is initiated, researchers can predict by using mathematical modeling that this person will live at least an additional 50 years – that is, close to normal life expectancy” (Dieffenbach and Fauci, 2011: 1). “The development of antiretroviral therapy represents one of the most important medical breakthroughs of the last 50 years. Today, 33 medications from six different antiretroviral classes... have been brought to market by the pharmaceutical industry” (AIDS2031 Consortium, 2010: 36). In the past decade, highly active antiretroviral therapy (HAART) has become simpler, better tolerated, less toxic, more effective and less expensive (Ambrosioni et al., 2011). Between 1995 and 2009, an estimated 14.4 million life-years have been gained among adults as a result of ART (Mahy et al., 2010b). Scientists are currently trying to devise methods to deliver antiretroviral treatment that are less dependent on adherence (Rohan et al., 2009 cited in Padian et al., 2011) and, while no documented cases of a true cure exist (Dieffenbach and Fauci, 2011), for the first time, scientists are beginning to discuss how to develop a cure for HIV, and clinical trials are currently underway (Richman et al., 2009 cited in Padian et al., 2011).
This section does not provide clinical guidance, which is available from WHO, but rather a public health perspective on what works for women to access treatment, adhere to antiretroviral therapy and to reduce transmission and stay healthy.“A major success in the third decade of the epidemic has been the expansion of HIV care and treatment in the developing world” (Dieffenbach and Fauci, 2011: 2). Between 2001 and 2010, the number of people receiving antiretroviral treatment rose nearly 22-fold. Antiretroviral treatment coverage rose 20% in sub-Saharan Africa between 2009 and 2010 alone (UNAIDS, 2011b). "Expanded access to antiretroviral therapy is reducing AIDS mortality rates in sub-Saharan Africa" (WHO et al., 2011b: 25). In low- and middle-income countries, 47% of the 14.2 million eligible people living with HIV were on antiretroviral therapy at the end of 2010, compared to 39% at the end of 2009 (UNAIDS, 2011b). Around the world, access to treatment is increasing: Botswana, Namibia and Rwanda, Cambodia, Chile, Croatia, Cuba, Guyana, Nicaragua and Slovakia have at least 80% of those needing antiretroviral treatment accessing treatment; for Swaziland, Zambia, Argentina, Brazil, Dominican Republic, Mexico and Uruguay reach at least 70% of those needing antiretroviral therapy (WHO et al., 2011b). In South Africa, “the scale-up of antiretroviral therapy from about 10% coverage in 2005 among those in need of treatment to more than 60% in 2009 has been a remarkable medical accomplishment” (Klausner et al., 2011: 293). In addition, initial results of studies show that people are being initiated on ART earlier, at higher CD4 counts (Lahuerta et al., 2012; Fox et al., 2012). "The global response to scaling up access to antiretroviral therapy in resource-limited settings has been rapid and dramatic and represents one of the largest public health successes in history” (Fox and Rosen, 2010: 11).
The benefits of HAART are widely known to increase life expectancy, quality of life and the ability to work and perform daily activities for people living with HIV (Antiretroviral Therapy Cohort Collaboration, 2008; Beard et al., 2009; Iwuji et al., 2011; Rosen et al., 2010; Jahn et al., 2008; Stover et al., 2008). A woman in Tanzania noted that the scale up of treatment in her country reduced the stigma surrounding HIV: “I see that... I am not the only one. Now it is the whole of Tanzania” (Roura et al., 2009: 4).
Treatment Programming Must Continue to be Scaled-Up
“Urgent efforts are needed to scale up antiretroviral therapy programmes to reach the 7.6 million people who were eligible for treatment at the end of 2010 (those with CD4 counts less than 350) but who were not receiving it” (UNAIDS, 2011b: 43). In 2010, almost two million AIDS-related deaths occurred (Zachariah et al., 2011b). Inadequate access to antiretroviral therapy and stock-outs will hinder improved health for those living with HIV and reducing transmission to HIV negative partners (Geng et al., 2010a; Oliveira et al., 2010a). The Millennium Development Goals include achieving universal access to HIV prevention, treatment, care and support by 2010 and to “halt and reverse the spread of HIV/AIDS by 2015.” As a recent report of the All Party Parliamentary Group on AIDS in the UK noted in July 2009, “We are not on track for either target” (All Party Parliamentary Group on AIDS, 2009: 5). In addition, all those millions of people who do get on treatment will need to continue being treated, cared for and supported for many decades to come.
Treatment is a good investment. A 2011 study indicated that investment in antiretroviral therapy programs to date results in gains of US$34 billion in addition to 18.5 million life years by 2020 (Resch et al., 2011), with findings indicating “a stream of economic benefits that is likely to offset substantially or exceed the costs of delivering AIDS treatment…” (Resch et al., 2011: 6). Many studies have shown that providing ART is cost-effective, in addition to improving quality of life, employment with other positive outcomes (Koenig et al., 2011; Walensky et al., 2011; Beard et al., 2009; Rosen et al., 2010; Iwuji et al., 2011). Conversely, “failure to scale up ART… would mean a sizable reduction in national economic activity, many fewer healthcare workers and teachers and worse educational outcomes for today’s generation of children, in additional to the humanitarian impact of increased mortality” (Holmes et al., 2010a: 177). A recent analysis by the Global Fund found that economic returns on AIDS treatment, through improved worker productivity and by averting future costs to care for children orphaned by the epidemic may equal or outweigh the costs of treatment (GFTAM, 2010 cited in AIDS2031 Consortium, 2010).
Women Have Particular Treatment Needs and Risks
Among 109 reporting countries, the estimated antiretroviral coverage was higher among women (53%) than men (40%) (WHO et al., 2011b). However, while more women than men have accessed treatment globally, structural factors and traditional gender norms can jeopardize women’s adherence, retention in care and their ability to prevent acquisition (if HIV-negative) or reduce transmission (if HIV-positive). [See Strengthening the Enabling Environment] Women have unique needs and while many treatment strategies have been evaluated as a whole, very little sex-disaggregated data or analyses have been published to date to evaluate what works, specifically, in treatment for women.
Drug resistance, for example, is a risk for everyone. “Once interrupted, the effects of ART are rapidly reversed and additional harms can accrue through the emergence of drug resistance mutations that limit future drug options and increase mortality” (Bangsberg, 2008; Deeks et al., 2009 cited in Geng et al., 2010b: 234-235). In 2009, five surveys showed transmitted drug resistance of between 5% and 15% (WHO et al., 2011b). An aggregate analysis of 15 surveys from 5 countries found that 6% of 2,150 people initiating first-line antiretroviral treatment had some form of baseline HIV drug resistance. After 12 months of therapy, 10% had viral failure, with 69% of these having detectable drug resistance (WHO et al., 2011b). Studies conducted in Vietnam, Nigeria and an Indian city with high HIV-infection rates showed that the prevalence of transmitted HIV drug resistance is low at under 5%, but periodic population-based surveillance of transmitted HIV drug resistance remains a key strategy in monitoring emergence of drug resistant strains (Nhung et al., 2012; Etiebet et al., 2012b; Chaturbhuj et al., 2010).
Women, however, may be at greater risk for becoming drug resistant themselves or transmitting drug resistant strains due to the temporary use of antiretrovirals to reduce perinatal transmission. Further evaluation is needed to understand these risks. While it is clear that those who go on ARV therapy for their own treatment needs should not interrupt treatment (Fauci, 2009a; SMART, 2006), treatment interruption for women who are on HAART simply to prevent perinatal transmission rather than for their own health needs has never been evaluated. "The risk for maternal health of stopping… maternal triple ARV prophylaxis after breastfeeding cessation is unknown” (WHO, 2010i: 47) – especially if an HIV-positive woman has multiple pregnancies. [See Antenatal Care - Treatment]
The WHO’s early warning indicators (EWI) on drug resistance have been employed to good effect (Hong et al., 2010). But some studies have shown that rates of transmission of drug resistant mutations are increasing in East and Southern Africa (Price et al., 2011; Hamers et al., 2012a) and concerns have been raised that if second-line therapies are not rolled out immediately, prevalence of transmitted drug resistance could increase (Gerberry and Blower, 2012). Surveying for drug resistance – especially in areas that already have high levels of transmitted drug resistance – is warranted (Sungkanuparphy et al., 2011 cited in Jordan, 2011). One way to avert drug resistance is to test the viral load in patients. If a regimen is failing, drug resistance can develop. “Viral load testing is the gold standard for monitoring patients on ART, where resources are available” (Sawe and McIntyre, 2009: 463). WHO recommends the use of viral load testing even in resource limited settings. “The time has come to work toward the progressive introduction of appropriate viral load monitoring technology in these programs with the same sense of urgency and commitments as the world approached ART access. To do less is to abandon the global success of ART to an early collapse” (Sawe and McIntyre, 2009: 464).
A recent review found that gender-specific differences in recommendations concerning initiation of therapy are not warranted (Floridia et al., 2008). An analysis of United States Food and Drug Administration (FDA) databases also found “no clinically or statistically significant gender differences” in 48-week efficacy of ART in randomized controlled trials between 2000 and 2008 (Stubbel et al., 2009).
Recent WHO recommendations concerning provision of triple antiretroviral therapy for pregnant women may result in earlier ART initiation for pregnant women. [See Antenatal Care - Treatment] In addition, there are indications that certain interventions can be highly beneficial to women specifically in treatment provision and access, adherence and support, and reducing transmission.