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Dennis Sifris, MD and James Myhre

How Likely Are We to Achieve Global HIV/AIDS Goals by 2015?

By January 1, 2014

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nullWith 2013 now firmly behind us, many are looking ahead to coming year to assess how close we are to achieving the targets set by the United Nations back in 2000 with the establishment of the so-called Millennium Development Goals (MDG).

Among the eight targets outlined in the MDG is call to "halt and reverse" the spread of HIV, tuberculosis and malaria by 2015. Since 2010, a number of organizations, including the Joint United Nations Programme on HIV/AIDS (UNAIDS), have set specific and measurable targets -- aiming to reduce not only the global prevalence and incidence of HIV, but many of the social barriers that continue to confound progress (e.g., stigma, gender violence, criminalization of HIV).

This week, we take an unbiased look at some of the key targets and ask if we are realistically on track to achieving them (or if there are any questions or concerns that we have still yet to address).

Goal #1: Reduce sexual transmissions of HIV by 50%

FACTS: From 2001 to 2011, the number of people newly infected with HIV dropped by approximately 21%. While much coverage has been given to a September 23 report from UNAIDS citing a 33% drop in new infections, that number included both adults and children. So from the perspective of sexual transmissions alone, we've still have a long way to go before reaching the goalpost standard of 50%.

Still, there are bright spots, particularly in the Caribbean where the new infection rate has plummeted by some 43%. Additionally, increased antiretroviral coverage may help bolster numbers in Sub-Saharan Africa, which keeps slightly ahead of the curve with an estimated 25% reduction during the same period.

LIKELIHOOD OF SUCCESS: Difficult, but possible in a few key regions.

With increasing concerns about the sustainability of funding from donor countries, greater focus will likely be placed on high-impact countries that are more able to scale programs and effect significant reductions in new infections.

By contrast, it is unlikely we'll see any reversals in Eastern Europe or Central Asia, where infection rates have doubled since 2001 (and whose epidemics are driven primarily  by injection drug use). Similarly, the failure to stave HIV infections among men who have sex with men (MSM) will likely contribute to the upward trend we're seeing in many developed and non-developed countries.

Goal #2: Put 15 million HIV-positive people on antiretroviral therapy.

FACTS: Currently, about eight million people in developing countries have been placed on antiretroviral therapy (ART). Expanded treatment guidelines issued by the World Health Organization (WHO) earlier this year -- whereby therapy can now be initiated at CD4 counts under 500 cells/mL -- increased the potential for ART access.

Despite these advances, the MDG target was entirely missed in 2010, wherein only 55% of the 14.4 million people in need of ART actually received it.  Moreover, only 28% of eligible children had access to ART, less than half than of women (63%).

To date, the highest coverage has been achieved in Latin America and the Caribbean (68%), with Eastern Europe and Central Asia demonstrating the weakest coverage (19%).

LIKELIHOOD OF SUCCESS: Fair to good.

Based on statistical trends alone, it is possible that 15 million will be placed on ART by the end of 2015. Additionally, as global funding is projected to rise only moderately in the next two years, it is likely that greater focus will be placed on increasing ART coverage as other preventative strategies (like voluntary male circumcisions) take a backseat role.

Meanwhile, the successful procurement of antiretrovirals in countries like South Africa (where an Atripla generic now costs around $8 per month) ensures greater access  for moderate- to low-income populations.

However, the ambitious ramping-up of ART delivery may negatively impact countries where the healthcare infrastructure is already strained. While registrant number may look good on paper, there remain widespread concerns about drug adherence (largely unmonitored outside of sentinel testing sites) and the impact of non-adherence on community drug resistance.

And, unless infection rates can be brought down by least 50% by 2015, many question whether a global ART initiative can be sustained in the face of an ever-increasing HIV population.

Goal #3: Eliminate mother-to-child transmission of HIV and reduce AIDS-related maternal deaths by 50%.

FACTS: In June 2013, UNAIDS reported that seven African countries demonstrated a 50% reduction in new HIV infections among children since 2009. Much of the success is due to antiretroviral programs design to prevent mother-to-child transmission (MTCT), with an impressive 75% program coverage in many priority countries. In South Africa alone, MTCT rates have dropped to an astounding 5%, down from a high of 37% in 2000.

From a worldwide perspective, the picture is not quite as rosy. Currently, only 57% of pregnant women with HIV are receiving the ART they need.

In terms of child mortality, the MDG called for a reduction in HIV-related maternal deaths to 38 deaths per 100,000 births by 2015. To date, a number of countries are starting to make healthy inroads, with South Africa reporting 60 HIV-related deaths per 100,000 births as of 2011.

LIKELIHOOD OF SUCCESS: Promising.

Based on South Africa's success, it is not difficult to envision a 90% or greater reduction in MTCT by 2015. This is primarily due to the fact that Sub-Saharan Africa alone represents 93% of the pregnant women in need of ART.

Meanwhile, with MTCT interventions nearing 90% in countries like Botswana and Namibia, near-universal coverage almost ensures program success within the region. Maybe not to eliminate MTCT altogether, but to do a pretty amazing job at reducing incidence to levels previously thought unattainable.

By contrast, infant mortality remains a challenge despite a reduction in MTCT. Although the number of children receiving ART has increase by 15% from 2009 to 2011, the pace remains well under that of adult men and women during the same period (21%).

Efforts need to be intensified in order to ensure early infant diagnosis, particularly among low-resource populations. According to UNAIDS, coverage of infant diagnostic service was well under 5% in in a number of key priority states.

Goal #4: Halve the number of tuberculosis deaths in people living with HIV.

FACTS: The global target calls for a reduction in tuberculosis (TB)-related deaths among people living with HIV to less than 250,000 by 2015. While 430,000 people living with HIV were reported to have died of TB in 2011, steady progress has been made in recent years.

Between 2004 and 2011, 17 out of 44 countries with high HIV/TB prevalence reported greater than 50% reductions in death among people with HIV. Overall, there has been a 38% reduction, bolstered largely by intensified TB identification, greater infection control, and widespread use of prophylactic medication to prevent TB infection in vulnerable HIV populations.

LIKELIHOOD TO SUCCESS: Good.

The increased use of ART in people with HIV inherently decreases the incidence of TB within that population. More effective delivery of TB treatment (in the way of so-called "directly observed therapy" or DOT) has resulted in an impressive 85% cure rate worldwide.

That said, there are a number of challenges that hinder progress. Currently, more than a third of TB treatment centers do not offer DOT, while most cases of multi-drug resistant TB are neither diagnosed nor treated in accordance with WHO guidelines.

Far more concerning is the fact that, of the countries with high HIV/TB prevalence, only Kenya and Malawi are delivering ART to more than 50% of HIV-positive TB cases. Further progress needs to be made to ensure reduced TB-related mortality within these regions.

Image credit: Joint United Nations Programme on HIV/AIDS (UNAIDS)

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