Measures of HIV treatment progress highlight lagging investments

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Greater investment, established goals needed to realize antiretroviral treatment benefits of reducing new infections, improving health, and lengthening life expectancy, pieces say

While the proven transmission-preventing, health-improving, life-saving benefits of antiretroviral treatment for HIV, along with rising numbers of infected people receiving the medicine have inspired talk in recent years of an “AIDS-free generation,” efforts needed to achieve that goal are falling short of what is needed, and in some aspects are regressing, according to two recent articles.

One, Political factors behind US global AIDS programmes slowdown, published in The Lancet today, points to a steep drop last year in the numbers of new patients receiving antiretroviral treatment through U.S. support — the largest  source by far of pepfartrtmentscaleupsupport for HIV prevention and care efforts in sub-Saharan Africa where prevalence of the virus is highest.

Following news in 2011 that antiretroviral treatment for people living with the virus was one of the most effective means of slowing the spread of HIV as well as saving lives, the Obama administration set a World AIDS Day goal of 6 million people on treatment — quadrupling the number on treatment at the start of his administration — and by 2013 the U.S. President’s Emergency Plan for AIDS Relief had surpassed it.

Since then, the piece points out, a reserve of PEPFAR-devoted dollars ran out, while funding had already dropped. Another big difference, the  piece, by Matthew Kavanagh, Jamila Headley and Asia Russell of Health GAP says, is that last year was the first since the beginning of PEPFAR without a “presidentially set” target to give planners something to shoot for. Those targets, the authors say, has put PEPFAR ahead of other aid programs. Without a target last year, PEPFAR’s antiretroviral treatment enrollment dropped to about 1.1 million, or 65 percent of the previous year’s enrollment, the authors note. The Lancet piece includes a chart from State Department data of PEPFAR treatment enrollment over the last eight years, and Headley also sent along the enrollment numbers over the last four years, spelling out the rising, and then reversing trend, with:

  •  691,741 people starting treatment through PEPFAR support in 2011;
  • 1,247,651 in 2012;
  • 1,697,709 in 2013;
  • 1,121,711 in 2014

CIDThe analysis of that trend follows a study in Clinical Infectious Diseases tracking another trend — how sick people are by the time they are diagnosed with HIV and by the time they begin antiretroviral treatment. Guidelines for starting treatment have changed in recent years, with the World Health Organization recommending earlier treatment, at higher immune cell counts, the authors of the analysis Trends in CD4 Count at Presentation to Care and Treatment Initiation in Sub-Saharan Africa, 2002-2013, point out. In 2010 the World Health Organization recommended patients start antiretroviral treatment when their immune cell, or CD4, counts had dropped to 350 cells per cubic milliliter, rather than the previous recommendation of waiting until the count had dropped to 200. In 2013, the WHO raised the number again, recommending patients start treatment if their immune cell count had dropped to 500. But the authors, who analyzed data from 186 articles published between 2002 and 2013, discovered that reality not only hasn’t kept up with guidelines, but has changed little in response to them. They found that while the average immune cell count of patients showing up for care was 250 in 2002, and 309 in 2012, average immune cell counts when starting antiretroviral treatment were 152 in 2002 and 140 in 2012. Changing those numbers will require greater investment in diagnosing HIV earlier, and in making care accessible faster on the part of donors, the authors say.

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