TOWARDS UNIVERSAL ACCESS? Scaling up priority HIV/AIDS interventions in the health sector Yves Souteyrand, WHO October 2011
Towards universal access targets UN General Assembly High level Meeting June 2011, New York: political declaration on HIV/AIDS 2015 targets increase the number of people on life saving treatment to 15 million in 2015 Halve TB deaths in People living with HIV push towards eliminating new HIV infections among children in the next five years.
Data collection in 2010 Joint WHO/UNICEF/UNAIDS reporting tool disseminated to countries in January 2010. Data collection is country-led in collaboration with country offices of WHO, UNICEF and UNAIDS. Country reports were submitted between March and April 31 March 2010, followed by regional and global cross-validation with partners. 183 countries reported data for 2010 (144 low- and middle-income and 39 high-income countries) The report also includes data from population-based and other special surveys, as well as scientific literature.
Global Highlights The year 2010 saw continued progress in expanding health sector interventions for HIV prevention, treatment and care in low- and middle-income countries. Universal access has been achieved in some countries for some interventions (80% coverage), including in countries with generalized epidemics (Botswana, Namibia) In all areas, global and regional progress are reported Impact of HIV/AIDS response starts being well documented But progress is uneven between regions and between interventions Gaps are huge for all interventions Concerning results regarding retention, stock out, awareness of HIV status The economic context is concerning Sustainable and increased funding is needed Quality and efficiency of delivery can be improved
Antiretroviral Therapy and Paediatric ART
Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 2002 2010 7 Millions 6 5 4 3 North Africa and the Middle East Europe and Central Asia East, South and South-East Asia Latin America and the Caribbean Sub-Saharan Africa 2 1 0 End 2002 End 2003 End 2004 End 2005 End 2006 End 2007 End 2008 End 2009 End 2010
Treatment and care More than 6.6 million people received antiretroviral therapy at the end of 2009, a 27% increase in one year In Sub-Saharan Africa 5.1 million received ART (+ 29%in one year) Overall ART coverage is lower than 50% Around 7.5 million people still in need (based on WHO 2010 guidelines) Coverage is higher for women (39% in 2009) than for men (31%) The number of health facilities providing ART in 2010 was 22,369, a 18% increase in one year, was an average of patient per facilities of 297 (484 in Sub- Saharan Africa)
Treatment and care The vast majority of adults on treatment are receiving first-line regimens (<3% receive second-line regimens in countries outside the Americas Regions). Data on patient retention show that most attrition from treatment programmes occurs during the first year of treatment initiation (18% lost of follow-up after one year) and rates tends to stabilize thereafter.
Retention on antiretroviral therapy up to 48 months, 2008 and 2009
Comparison of number of men and women receiving and estimated to need antiretroviral therapy and percentage coverage, by region, December 2009 a
Number of people (all age groups) receiving and needing antiretroviral therapy, and percentage coverage in low- and middle-income countries by region, 2008 to 2009
Percentage of children living with HIV receiving antiretroviral therapy in low-and middle-income countries 2005, 2008, 2009
Percentage of children living with HIV receiving antiretroviral therapy in low- and middle income countries, 2005, 2009, and 2010 2005 2009 2010 80% % of children younger than 15 years living with HIV receiving antiretroviral therapy 70% 60% 50% 40% 30% 20% 10% 0% 5% 21% 20% Sub-Saharan Africa 6% 26% 23% Eastern and Southern Africa 1% 10% 9% Western and Central Africa 34% 55% 42% Latin America and the Caribbean 42% 61% 46% Latin America 32% 31% 6% Caribbean 12% 40% 39% East, South and South- East Asia 17% 56% 65% Europe and Central Asia 0% 4% 5% North Africa and the Middle East 6% 21% 23% Total lowand middleincome countries
Paediatric ART In 2010, in 66 reporting countries, less then 30% of children born to HIVpositive mothers received an HIV test within the two first two months of life. The number of children below the age of 15 years on antiretroviral therapy rose from 356 400 in 2009 to 456 000 in 2010. Coverage is lower than 25%
CD4 cell count and viral load measurement capacity In 66 reporting countries (2010): 2,155 facilities equipped to perform CD4 count tests and 394 facilities for viral load measurement. Twelve countries reported having no viral load capacity. A total of 3,935,000 CD4 tests and 1,175,000 viral load measurements were performed in 2010. Average number of patient per laboratory in SSA: 2300 for CD4; 39500 for VL
Antiretrovirals for PMTCT
E-MTCT targets Indicator Number HIV+ women delivering Maternal ARV prophylaxis coverage ART coverage for pregnant women ART for children New paediatric infections Deaths due to HIV among children < 5 Baseline 2009 1,486,000 48% 34% 21% 429,000 162,000 Target 2015 743,000 90% 90% 100% <43,000 <81,000
HIV services for pregnant women More than 55% of pregnant women living with HIV received antiretrovirals to reduce the risk of transmitting HIV to their infants, up from 48% in 2009 and 14% in 2005. 18 countries have reached over 80% coverage, including Botswana, Lesotho, Namibia, South Africa and Swaziland More women are receiving efficacious combination antiretroviral drug regimens to prevent mother-to-child transmission 50% HIV-positive pregnant women are not assessed for their eligibility to receive antiretroviral therapy for their own health
Percentage of pregnant women living with HIV receiving antiretrovirals for preventing mother-to-child transmission of HIV in low- and middle-income countries by region, 2005, 2008 and 2009
Percentage of pregnant women living with HIV receiving any antiretrovirals for PMTCT 2005 2009 2010 % of pregnant women living with HIV receiving antiretroviral drugs for preventing mother-to-child transmission 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 14% 49% 60% Sub- Saharan Africa 18% 62% 78% Eastern and Southern Africa 4% 21% 18% Western and Central Africa 51% 78% 77% Latin America and the Caribbean 64% 82% 80% Latin America 73% 62% 24% Caribbean 11% 31% 32% East, South and South- East Asia 60% 81% 88% Europe and Central Asia 7% 4% 0% North Africa and the Middle East 14% 48% 59% Total lowand middleincome countries
Percentage distribution of various antiretroviral regimens provided to pregnant women in low- and middle-income countries in 2007, 2009 and 2010 Distribution of antiretroviral regimens for the prevention of mother-to-child transmission of HIV (%) 100% 80% 60% 40% 20% 0% 18% 30% 49% 57% 54% 33% 9% 23% 15% 9% 1% 2007 2009 2010 2% Uncategorized Antiretroviral therapy Combination regimen Single-dose nevirapine
Contribution of the 25 countries with the largest number of women needing antiretrovirals for preventing mother-to-child transmission of HIV to the global gap in reaching 80% of those in need, 2009
Testing and Counselling
HIV testing and counselling The number of HIV tests performed increased globally. A total of 79 million people tested in 2009 (from 47 per 1000 people per year in 2009 to 55 in 2010) Population surveys conducted in 18 low-and middle-income countries between 2007 and 2009: a median of 12% women and 7% men have been tested in the 12 months previous to the surveys a median of 34% women and 17% men have ever been tested Population surveys conducted in low-and middle-income countries show that knowledge of HIV status remains inadequate: the median percentage of people living with HIV who know their status is estimated at below 40%.
Percentage of women and men who received an HIV test and test results in the 12 months preceding the survey in countries with repeat population surveys, 2003 2009
Percentage of people living with HIV who have ever received an HIV test and their test results prior to the survey: national population surveys, 2003-2008 Figure 4.2. Percentage of people with HIV who have ever been tested and received their test results prior to the survey, repeat population surveys 2003-2008 80,0 70,0 60,0 50,0 40,0 30,0 20,0 22,8 18,2 73,5 58,6 16,8 16,4 70,8 51,8 21,5 20,2 43,7 30,8 Women Men 10,0 0,0 2003 2008 2004 2009 2003-04 2007-08 Kenya Kenya Lesotho Lesotho Tanzania, United Republic of Tanzania, United Republic of
Testing and counselling for pregnant women Around one third of the 125 million pregnant women in low- and middleincome countries received an HIV test in 2010, up from 26% in 2009. Less than 50% of pregnant women testing positive were reported to have been assessed for eligibility to receive antiretrovirals for their own health.
Percentage of pregnant women who received an HIV test in low- and middle-income countries 100% 90% 2005 80% 70% 60% 50% 40% 30% 20% 10% 0% 9% 29% 35% 42% Sub-Saharan Africa 15% 45% 52% 61% Eastern and Southern Africa 25% 21% 16% 3% Western and Central Africa 61% 61% 56% 53% 56% 53% 29% 29% Latin America & Caribbean Latin America 62% 60% 56% 24% Caribbean 40% 59% 57% 51% Europe & Central Asia 0% 0% 1% 1% Middle East and North Africa 18% 12% 2% 30% East, South & South East Asia 26% 21% 7% 2008 2009 2010 35% Total low - and middleincome countries
Percentage of pregnant women who received an HIV test in low- and middle-income countries by region, 2005, 2008, 2009
Testing and counselling: TB/HIV Testing and counselling is recommended for people presenting signs/symptoms of TB and people with confirmed TB In 2010, 2.4 million TB patients knew their HIV status, representing 34% of notified cases (up from 28% in 2009 and 3.2% in 2004). Among them 488 000 were HIV-positive (23%)
Conclusion Reaching 15 million target mean continuous efforts for scaling up ART initiation and sustaining long term treatment. Treatment 2.0 identifies priorities for making treatment simpler, cheaper and better Uptake of testing and counselling is increasing but does not reach key populations and links with interventions is often weak, including for pregnant women and TB/HIV infected people Phase out Sd-NVP is progressing but still a proportion of pregnant women are receiving less efficient regimens Coverage of interventions targeting children is lagging behind