Last year, we celebrated 30 years of progress in the fight against AIDS. This year, let’s celebrate World AIDS Day by looking forward. We’ve challenged ourselves by setting an ambitious goal of an AIDS-free generation. Let’s examine where we are on our way to that goal.
A recent model known as the HIV treatment cascade helps identify the key opportunities to improve services to stop the spread of HIV (see figure). Getting into the treatment cascade begins with HIV testing, because knowing whether one is infected or not determines the next course of action.
We have evidence that helping people to complete each step in this cascade is crucial both to assuring the individual’s health and to achieving the public health goal of an AIDS-free generation. We can use the cascade model to help gain accurate assessments of the “leakage points” in the HIV care and treatment system. By knowing where in the cascade we need to focus, we can provide additional incentives for patients and resources for providers to improve retention.
At the individual level, this means, everyone needs to take the initiative to learn his or her HIV status. At the population level, health systems need to make universal HIV testing the norm. Determining HIV status is the first step to applying prevention and treatment technologies that have maximum public health impact.
If diagnosed with HIV infection, the individual continues down the cascade to referral for HIV care, receiving HIV therapy, adhering to HIV treatment and finally lowering the viral load level to immeasurable — essentially non-transmissible — levels.
So what stands in our way? Health care providers hear all the time that people don’t get tested because they think their risk of HIV infection is low. Overburdened health care facilities sometimes drop the ball in referring people for testing. Creative approaches to overcoming these barriers are being imagined every day. For example, make testing the norm, with opt-out procedures instead of opt-in. The clinical study known as HPTN 065 is using this approach as part of its evaluation of the feasibility of an enhanced community-level test and link to care. Other strategies include offering incentives for being tested, mobile HIV testing outlets with rapid diagnosis, using mass communication to emphasize the importance of early treatment and to encourage people to return for their test results, and utilizing new home HIV test kits.
A person who tests positive must be linked to HIV service delivery points. More barriers appear at this stage. Because they feel healthy, people don’t begin treatment. Even more critical, many fear their HIV status leaves them vulnerable to stigma. New policies and social change are needed to relieve more of this vulnerability. Often the benefits of early treatment, for both themselves and others, have not been communicated, particularly when it comes to the newer idea of treatment as prevention. Many have questions about starting treatment early and dealing with potential side effects. These are important questions that we need to address.
More creative and sensitive approaches can help overcome some of these barriers: promotion of the benefits of immediate enrollment through digital reminders, hotlines for clients and targeted communications to those who have just been tested. At the facility level, strengthen the links between testing and care centers. Provide performance incentives for achieving referral quotas. Let’s encourage those in treatment to remain adherent by sending reminders through mobile phones, delivering care or medicine to their homes and establishing peer support.
Different countries are using the cascade approach to improve their HIV service delivery among the populations at highest risk. In Zambia for example, where heterosexual transmission is the dominant mode, the rate of transmitting HIV from mother to child dropped more than three-fold when combining HIV testing with administering antiretroviral drugs to both mothers and newborns. In Vietnam, where injecting drug use has driven the epidemic, finding and treating drug users who have HIV has been a focus for the cascade approach.
We’ve come so far in the battle against this virus. Today, for those who have access to antiretroviral treatment, HIV can be managed as a chronic illness. Better still, with encouraging scientific breakthroughs in HIV prevention tools, fewer people have to go through the trauma of getting that diagnosis at all. In many places, especially in Africa, men are voluntarily receiving medical circumcisions, proven to help reduce transmission of the virus. Others — some with the virus, some without — are taking antiretroviral drugs to prevent HIV spread. Both of these strategies have achieved “proof of concept status,” meaning there’s good scientific evidence that they work. We continue searching for a vaccine to prevent the virus and a cure for those who already have it.
As we pause to reflect on 2012’s World AIDS Day, let’s resolve to get everyone on board to make the most of the tools we have. We can conquer this disease.