World AIDS Day is observed each year on Dec. 1 to raise awareness about HIV and increase efforts toward the eradication of AIDS, according to a press release.
This year’s theme, “The Time to Act is Now,” highlights the urgent need to implement the best evidence-based HIV prevention strategies.
The most effective strategy is to ensure that all people with HIV are made aware of their status and adhere to treatment, according to the NIH. Nearly a third of all new infections in the United States are transmitted by people who do not know their status, and 60% of new infections are transmitted by people who are diagnosed but not in care.
Deborah L. Birx
The CDC reported that nearly 37 million people are living with HIV/AIDS worldwide. Several organizations including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) helped reduce AIDS-related deaths by 42% since 2004, and new HIV infections by 35% since 2000, the release said. During this year’s Congressional Black Caucus Foundation’s annual Africa BrainTrust event, U.S. Ambassador Deborah L. Birx, MD, global AIDS coordinator and special representative for Global Health Diplomacy at the State Department, said PEPFAR has invested nearly $750 million per year into the health systems of developing countries. However, more efforts are needed to achieve the “AIDS-free generation” that President Obama said was possible during his 2013 State of the Union address, Birx said.
Less than half people with HIV infection are receiving ART, according to a joint statement released by Kenneth H. Mayer, MD, and Carol Dukes Hamilton, MD, co-chairs of IDSA’s and HIV Medicine Association’s Center for Global Health Policy. Researchers at Palladium, Washington, D.C., suggest these gaps in treatment may hinder “90-90-90” targets set by UNAIDS that aim to increase awareness of serostatus in 90% of people living with HIV; ensure 90% of infected patients are receiving ART; and to achieve 90% viral suppression in all patients receiving ART. The overall goal of the 90-90-90 targets set are designed to end the AIDS epidemic by 2030.
Kenneth H. Mayer
Researchers predicted ART coverage rates in 2020 using an uncertainty model reflecting specific epidemiological and demographic data from 97 countries, including those with significant HIV epidemics. Coverage was assessed in three scenarios that assumed countries based ART eligibility on (1) current treatment criteria; (2) WHO’s 2013 guidelines, which recommend patients with HIV start therapy when their CD4 count is below 500 cells/mm³; and (3) WHO’s 2015 guidelines, which recommend patients receive treatment regardless of CD4 count.
The model estimated that 25.7 (95% CI, 25.5-26) million adults and 1.57 (95% CI, 1.55-1.6) million children would receive ART by 2020 under current criteria; 26.5 (95% CI, 26-27) million adults and 1.53 (95% CI, 1.52-1.55) million children would receive ART if all countries adopted WHO’s 2013 guidelines; and 30.4 (95% CI, 30.1-30.7) million adults and 1.68 (95% CI, 1.63-1.73) million children would receive treatment if countries implemented WHO’s 2015 guidelines. Based on these data, researchers concluded the average percentage of people eligible for ART under the current eligibility criteria (79%) will not be met by 2020.
In order to increase ART coverage, researchers estimated that $0.51 billion, $0.55 billion, and $0.73 billion investments are needed to support HIV testing under the current eligibility, WHO 2013, and WHO 2015 scenarios, respectively. In addition to HIV diagnostics, investments are also needed to reduce barriers related to stigma and discrimination, researchers wrote.
Financial resources needed to scale up ART in health care facilities are estimated to cost $45.8 (95% CI, 45.4-46.2) billion under the current scenario, $48.7 (95% CI, 47.8-49.6) billion under the WHO 2013 scenario, and $52.5 (95% CI, 51.4-53.6) billion under the WHO 2015 scenario. With recent external and domestic funding trends, the 6-year financing gap ranged from $19.8 billion to $25 billion.
When researchers replaced unit costs of adult first- and second-line ART regimens with the average cost of new, less-expensive regimens, such as those containing dolutegravir (Tivicay, GlaxoSmithKline), the total cost decreased by $7.3 billion. The development of long-acting injectable ART therapies and once-daily regimens for HIV treatment further reduced the cost of treatment.
“Our results indicate that the resources required for the global ART response may be less than previously estimated,” researchers wrote in PLOS Medicine. “However, financial resources mobilized for ART or technical efficiency will need to increase to meet the funding challenge. Even with optimistic assumptions about domestic source contributions, the financing gap is large.”
Based on current funding projections, researchers estimated that approximately 43% to 48% of resource requirements at the facility level for ART coverage will remain unfunded from 2015 to 2020.
“As donors place greater emphasis on domestic financing for HIV treatment, particularly in middle-income countries, countries will need to mobilize additional resources to fill the funding gap,” the researchers wrote. “Because of constrained resources for ART among external funders and among the governments of [low-income countries] and [lower-middle income countries], efficiency gains through treatment optimization and the introduction of new low-cost regimens could be the most promising initiatives for reducing global ART costs and the funding gap.
“As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective [ART] regimens…may prove to be ‘game changers’ that allow more people to be on ART with the resources available.”
Disclosure: The researchers report no relevant financial disclosures.