Sustaining communicable disease elimination efforts in the Americas in the wake of COVID-19.

The COVID-19 pandemic has disrupted implementation of health interventions and set back priority programs aiming to control and eliminate communicable diseases. At the same time, the pandemic has opened up opportunities to expedite innovations in health service delivery to increase effectiveness and position health on the development and political agendas of leaders and policy makers. In this context, we present an integrated, sustainable approach to accelerate elimination of more than 35 communicable diseases and related conditions in the region of the Americas. The Elimination Initiative promotes a life-course, person-centred approach based on four dimensions - preventing new infections, ending mortality and morbidity, and preventing disability - and four critical lines of action including strengthening health systems integration and service delivery, strengthening health surveillance and information systems, addressing environmental and social determinants of health, and furthering governance, stewardship, and finance. We present key actions and operational considerations according to each line of action that countries can take advantage of to further advance disease elimination in the region.

COVID-19 and inequities in the Americas: lessons learned and implications for essential health services.

The COVID-19 pandemic has exacerbated social, economic, and health-related disparities, which disproportionately affect persons living in conditions of vulnerability. Such populations include ethnic groups who face discrimination and experience barriers to accessing comprehensive health care. The COVID-19 pandemic has exposed these health disparities, and disruptions of essential health services have further widened the gaps in access to health care. Noncommunicable diseases are more prevalent among groups most impacted by poor social determinants of health and have been associated with an increased likelihood of severe COVID-19 disease and higher mortality. Disruptions in the provision of essential health services for noncommunicable diseases, mental health, communicable diseases such as HIV, tuberculosis, and malaria, and maternal and child health services (including sexual and reproductive health), are projected to also increase poor health outcomes. Other challenges have been an increased frequency of interpersonal violence and food insecurity. Countries in the Americas have responded to the disruptions caused by the pandemic by means of health service delivery through telemedicine and other digital solutions and stepping up social service support interventions. As vaccinations for COVID-19 create the opportunity to overcome the pandemic, countries must strengthen primary health care and essential health services with a view to ensuring equity, if the region is to achieve universal health coverage in fulfillment of the Sustainable Development Goals.

La pandemia de COVID-19 ha acentuado las desigualdades sociales, económicas y relacionadas con la salud, que afectan desproporcionadamente a las personas en situación de vulnerabilidad. Esta población incluye grupos étnicos que se enfrentan a la discriminación y obstáculos para el acceso a la atención integral de salud. La pandemia de COVID-19 ha expuesto estas desigualdades de salud, y las interrupciones de los servicios esenciales de salud han ampliado aún más las brechas en el acceso a la atención de salud. Las enfermedades no transmisibles son más prevalentes en los grupos que han sufrido un mayor impacto de los determinantes sociales de la salud deficientes y se han asociado con una mayor probabilidad de presentar un cuadro grave de COVID-19 y una mayor mortalidad. Asimismo, se proyecta que las interrupciones en la prestación de servicios esenciales de salud para las enfermedades no transmisibles, la salud mental, las enfermedades transmisibles como la infección por el VIH, la tuberculosis y la malaria, y los servicios de salud maternoinfantil (como la salud sexual y reproductiva) incrementen los resultados deficientes en materia de salud. Otros retos son una mayor frecuencia de la violencia interpersonal y la inseguridad alimentaria. Los países de la Región de las Américas han respondido a las interrupciones causadas por la pandemia con la prestación de servicios de salud mediante la telemedicina y otras soluciones digitales, y la aceleración de las intervenciones de apoyo de los servicios sociales. A medida que la vacunación contra la COVID-19 crea la oportunidad de superar la pandemia, los países deben fortalecer su atención primaria de salud y sus servicios de salud esenciales a fin de garantizar la equidad, para que la Región logre la cobertura universal de salud en cumplimiento de los Objetivos de Desarrollo Sostenible.

A pandemia de COVID-19 exacerbou as disparidades sociais, econômicas e as relacionadas à saúde, que afetam de maneira desproporcional as pessoas que vivem em situação de vulnerabilidade. Essas populações incluem grupos étnicos que enfrentam discriminação e barreiras para o acesso à atenção integral à saúde. A pandemia de COVID-19 expôs essas disparidades, e as interrupções nos serviços essenciais de saúde ampliaram ainda mais as lacunas no acesso aos cuidados de saúde. As doenças não transmissíveis são mais prevalentes entre os grupos mais afetados por determinantes sociais da saúde deficientes e estão associadas a um aumento na probabilidade de doença grave pela COVID-19 e mortalidade mais elevada. Prevê-se que as interrupções na prestação de serviços essenciais de saúde para doenças não transmissíveis, saúde mental, doenças transmissíveis como HIV, tuberculose e malária, bem como dos serviços de saúde materno-infantil (incluindo saúde sexual e reprodutiva) também aumentem os desfechos adversos de saúde. Outros desafios são o aumento da frequência da violência interpessoal e insegurança alimentar. Os países das Américas responderam às interrupções causadas pela pandemia com a prestação de serviços de saúde por meio da telemedicina e outras soluções digitais, e a aceleração de intervenções de apoio dos serviços sociais. À medida em que a vacinação contra a COVID-19 oferece a oportunidade de superar a pandemia, os países devem fortalecer a atenção primária à saúde e os serviços essenciais de saúde com o objetivo de garantir a equidade, para que a região atinja a cobertura universal de saúde em cumprimento aos Objetivos de Desenvolvimento Sustentável.

[Social determinants and the Sustainable Development Goals' tuberculosis target in the AmericasDeterminantes sociais e a meta para a tuberculose dos Objetivos de Desenvolvimento Sustentável nas Américas]. / Determinantes sociales y meta de tuberculosis en los Objetivos de Desarrollo Sostenible en las Américas.

OBJECTIVE: Determine patterns of tuberculosis (TB) incidence indicators and number of deaths from TB within the framework of target 3.3 of the Sustainable Development Goals (SDGs) and their correlation with social determinants. METHODS: Ecological study methodology was used, in which the population is the unit of analysis. Social determinants were analyzed using a negative binomial regression model and strength of association. RESULTS: In the Americas, there was an average annual reduction in the TB incidence rate of 0.3% from 2009 to 2018; however, from 2015 to 2018, the rate increased, from 27.6 to 28.8 per 100,000 population. With regard to social determinants, the groups of countries with the lowest human development index (HDI) and gross domestic product (GDP) have a higher incidence of TB. TB risk in the country with the lowest HDI is six times that of the country with the highest HDI. CONCLUSIONS: At the current rate of reduction in the incidence rate and number of deaths from TB, the Region of the Americas will not meet the targets in the SDGs and in the End TB Strategy. Rapid implementation and expansion of interventions for TB prevention and control are required to attain the targets. This involves, among other actions, reducing access barriers to diagnosis and treatment and strengthening initiatives to address social determinants.

OBJETIVO: Determinar o comportamento dos indicadores de incidência da tuberculose (TB) e o número de mortes por TB no quadro da meta 3.3 dos Objetivos de Desenvolvimento Sustentável (ODS) e sua correlação com os determinantes sociais. MÉTODOS: Utilizamos uma metodologia de estudo ecológico, na qual a unidade de análise é a população. Para a análise dos determinantes sociais, utilizamos o modelo de regressão binomial negativo e a avaliamos a força das associações. RESULTADOS: Nas Américas, observou-se uma redução anual média na taxa de incidência de TB de 0,3% entre 2009 e 2018; entretanto, de 2015 a 2018 houve um aumento, de 27,6 para 28,8 por 100.000 habitantes. Com relação aos determinantes sociais, os grupos de países com índice de desenvolvimento humano (IDH) e produto interno bruto (PIB) mais baixos apresentam uma maior incidência de TB. O risco de TB no país com o menor IDH é seis vezes maior que no país com o maior IDH. CONCLUSÕES: Se mantido o ritmo atual de redução na taxa de incidência e no número de mortes por TB, a Região das Américas não alcançará as metas propostas nos ODS e na Estratégia pelo Fim da Tuberculose. É necessária uma implementação e expansão mais rápida das intervenções de prevenção e controle da TB para alcançar este objetivo. Isto implica, entre outras ações, reduzir as barreiras de acesso ao diagnóstico e tratamento e fortalecer as iniciativas que abordam os determinantes sociais.

Access to sexual and reproductive health services for women living with HIV in Latin America and the Caribbean: systematic review of the literature.

INTRODUCTION: Systematic reviews show that women living with HIV (WLHIV) have high unmet sexual and reproductive health (SRH) needs due to barriers to access sexual and reproductive health services (SRHS). In Latin America and the Caribbean (LAC), as of 2016, there were nearly one million WLHIV, but the existing evidence of their SRH needs comes from a few individual studies. This systematic review provides an overview of these women's needs to help define new and/or adapt existing public health strategies to the local context. This review synthesizes the evidence from the literature on the use of and access to SRHS related to family planning, antenatal care, abortion services and violence against WLHIV in LAC. METHODS: Using a systematic review of mixed studies, a search was performed in MEDLINE, EMBASE, LILACS, INASP, POPLINE, SCOPUS, for studies conducted in LAC, from 2004 to 2017, as well as contact with authors and hand search as needed. Two independent reviewers evaluated the quality of the studies using the Mixed Methods Appraisal Tool; inclusion was conducted according to the PRISMA flow diagram. An exploratory narrative synthesis followed by quantitative synthesis data was undertaken. Group analysis or meta-analysis was not considered appropriate given the level of heterogeneity of the studies. RESULTS: A total of 18 studies in 13 LAC countries for a population of 5672 WLHIV were included. Data from individual studies reported unmet family planning needs; higher, but inconsistent use of condom as the sole contraceptive method OR=1.46 [1.26 to 1.69]; lesser use of other non-permanent contraceptive methods OR=0.26 [0.22 to 0.31]; more unplanned pregnancies OR=1.30 [1.02 to 1.66]; more induced abortions OR=1.96 [1.60 to 2.39]; higher risk of immediate postpartum sterilization; and higher exposure to sexual and institutional violence by WLHIV when compared with women without HIV. CONCLUSIONS: This review presents evidence from LAC about the SRH unmet needs of WLHIV that must be addressed by decreasing institutional and structural barriers, facilitating services and reducing stigma, and discrimination among healthcare providers to improve access to SRHS based on human rights, so women independently of their HIV status can make their own reproductive decisions, free of violence and coercion.

Elimination of mother-to-child transmission of HIV and Syphilis (EMTCT): Process, progress, and program integration.

Melanie Taylor and colleagues discuss progress towards eliminating vertical transmission of HIV and syphilis.

Should HIV testing for all pregnant women continue? Cost-effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings.

INTRODUCTION: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings. METHODS: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each. RESULTS: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings. CONCLUSIONS: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.

Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America.

INTRODUCTION: Despite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre-exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost-effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America. DISCUSSION: Although demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost-effectiveness of PrEP. CONCLUSIONS: PrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high-risk individuals from key populations for higher cost-effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full-scale PrEP programmes.

Progress and challenges in implementing HIV care and treatment policies in Latin America following the treatment 2.0 initiative.

BACKGROUND: The Pan American Health Organization provides technical cooperation to countries in Latin America and the Caribbean for the scale-up of HIV care and treatment based on the Treatment 2.0 initiative. Fourteen Joint Review Missions (JRMs) were conducted between March 2012 and October 2014. Evaluating the degree of implementation of the recommendations of the JRMs and their impact on health policies, would help countries identify their gaps and areas for priority interventions. METHODS: A descriptive analysis of the JRM recommendations was conducted for eight countries. An in-depth cross-sectional retrospective analysis of the degree of implementation of these recommendations in Ecuador, Venezuela, Bolivia, and El Salvador was performed through a standardized self-administered questionnaire applied to key informants. A comparative quantitative analysis on the optimization of antiretroviral regimens 'before/after' JRMs was conducted in three of the latter four countries, using data reported in 2013 and 2014. RESULTS: The priority areas with most recommendations were the optimization of antiretroviral treatment (ART) regimens (n = 57), the rational and efficient use of resources (n = 27) and the provision of point-of-care diagnostics and monitoring tools (n = 26), followed by community mobilization (n = 23), strategic information (n = 17) and the adaptation of delivery services (n = 15). The in-depth analysis in four countries showed that the two priority areas where most progress was observed were the rational and efficient use of resources (62%) and the optimization of ART regimens (60%). Adaptation of delivery services, community mobilization and strategic information were rated at 52% and the provision of point-of-care diagnostics and monitoring tools 38%. The quantitative analysis on optimization evidenced a 36% reduction in the number of first-line and second-line ART regimens, a 5.4% increase in the proportion of patients on WHO-recommended first-line regimens, a 19.4% increase in the use of the WHO preferred first-line regimen, 51% increase in the use of WHO-recommended second-line regimens, and a significant reduction in the use of obsolete drugs in first- and second-line regimens (respectively 1 and 9% of regimens in 2013). CONCLUSIONS: A relatively good level of progress was perceived in the recommendations related to optimization of ART regimens. Challenges remain on the improvement of recommendations related to health system strengthening and the promotion and support aimed at community-based organizations as part of the response to HIV/AIDS in Latin America. The JRMs are a useful mechanism for providing coherent technical support to guide countries in the pursuit of a comprehensive response to HIV/AIDS in the Latin American region.

Hepatitis C in key populations in Latin America and the Caribbean: systematic review and meta-analysis.

OBJECTIVES: Summarize hepatitis C virus (HCV) prevalence in injecting (IDU) and non-injecting drug users (NIDU), men who have sex with men (MSM), sex workers, and prison inmates in Latin America and the Caribbean (LAC). METHODS: Systematic review on HCV prevalence in sub-populations in LAC. Databases searched from 1-1-2000 to 10-30-2013. INCLUSION CRITERIA: prevalence studies in sub-populations in LAC. HCV-antibody was marker for prevalence of current/past HCV infection and HCV-RNA for prevalence of HCV current infection. RESULTS: IDU HCV current/past infection presented highest prevalence, from 1.7 % in Colombia to over 95 % in Ciudad Juarez and Tijuana, Mexico and pooled regional anti-HCV prevalence was 49 % (CI 95 % 22.6-76.3 %). NIDU, MSM and sex workers anti-HCV prevalence was below 10 %, and pooled regional prevalence of 4 % (CI 95 % 2.6-4.5 %), 3 % (CI 95 % 1.7-4.5 %) and 2 % (CI 95 % 1.0-3.4 %), respectively. Prison inmates presented higher values, but prevalence decreased over the 15-year time span (p < 0.001). Current HCV infection from three countries showed prevalence under 10 % in prison inmates and 1-46 % among drug users. CONCLUSIONS: Disease burden is high and surveillance, prevention and treatment should target these groups in LAC.

HIV service delivery models towards 'Zero AIDS-related Deaths': a collaborative case study of 6 Asia and Pacific countries.

BACKGROUND: In the Asia-Pacific region, limited systematic assessment has been conducted on HIV service delivery models. Applying an analytical framework of the continuum of prevention and care, this study aimed to assess HIV service deliveries in six Asia and Pacific countries from the perspective of service availability, linking approaches and performance monitoring for maximizing HIV case detection and retention. METHODS: Each country formed a review team that provided published and unpublished information from the national HIV program. Four types of continuum were examined: (i) service linkages between key population outreach and HIV diagnosis (vertical-community continuum); (ii) chronic care provision across HIV diagnosis and treatment (chronological continuum); (iii) linkages between HIV and other health services (horizontal continuum); and (iv) comprehensive care sites coordinating care provision (hub and heart of continuum). RESULTS: Regarding the vertical-community continuum, all districts had voluntary counselling and testing (VCT) in all countries except for Myanmar and Vietnam. In these two countries, limited VCT availability was a constraint for referring key populations reached. All countries monitored HIV testing coverage among key populations. Concerning the chronological continuum, the proportion of districts/townships having antiretroviral treatment (ART) was less than 70% except in Thailand, posing a barrier for accessing pre-ART/ART care. Mechanisms for providing chronic care and monitoring retention were less developed for VCT/pre-ART process compared to ART process in all countries. On the horizontal continuum, the availability of HIV testing for tuberculosis patients and pregnant women was limited and there were sub-optimal linkages between tuberculosis, antenatal care and HIV services except for Cambodia and Thailand. These two countries indicated higher HIV testing coverage than other countries. Regarding hub and heart of continuum, all countries had comprehensive care sites with different degrees of community involvement. CONCLUSIONS: The analytical framework was useful to identify similarities and considerable variations in service availability and linking approaches across the countries. The study findings would help each country critically adapt and adopt global recommendations on HIV service decentralization, linkages and integration. Especially, the findings would inform cross-fertilization among the countries and national HIV program reviews to determine county-specific measures for maximizing HIV case detection and retention.

Use of third line antiretroviral therapy in Latin America.

BACKGROUND: Access to highly active antiretroviral therapy (HAART) is expanding in Latin America. Many patients require second and third line therapy due to toxicity, tolerability, failure, or a combination of factors. The need for third line HAART, essential for program planning, is not known. METHODS: Antiretroviral-naïve patients ≥18 years who started first HAART after January 1, 2000 in Caribbean, Central and South America Network (CCASAnet) sites in Argentina, Brazil, Honduras, Mexico, and Peru were included. Clinical trials participants were excluded. Third line HAART was defined as use of darunavir, tipranavir, etravirine, enfuvirtide, maraviroc or raltegravir. Need for third line HAART was defined as virologic failure while on second line HAART. RESULTS: Of 5853 HAART initiators followed for a median of 3.5 years, 310 (5.3%) failed a second line regimen and 44 (0.8%) received a third line regimen. Cumulative incidence of failing a 2nd or starting a 3rd line regimen was 2.7% and 6.0% three and five years after HAART initiation, respectively. Predictors at HAART initiation for failing a second or starting a third line included female sex (hazard ratio [HR] = 1.54, 95% confidence interval [CI] 1.18-2.00, p = 0.001), younger age (HR = 2.76 for 20 vs. 40 years, 95% CI 1.86-4.10, p<0.001), and prior AIDS (HR = 2.17, 95% CI 1.62-2.90, p<0.001). CONCLUSIONS: Third line regimens may be needed for at least 6% of patients in Latin America within 5 years of starting HAART, a substantial proportion given the large numbers of patients on HAART in the region. Improved accessibility to third line regimens is warranted.

Health outcomes and cost impact of the new WHO 2013 guidelines on prevention of mother-to-child transmission of HIV in Zambia.

BACKGROUND: Countries are currently progressing towards the elimination of new paediatric HIV infections by 2015. WHO published new consolidated guidelines in June 2013, which now recommend either 'Antiretroviral drugs (ARVs) for women living with HIV during pregnancy and breastfeeding (Option B)' or 'Lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV (Option B+)', while de facto phasing out Option A. This study examined health outcomes and cost impact of the shift to WHO 2013 recommendations in Zambia. METHODS: A decision analytic model was developed based on the national health system perspective. Estimated risk and number of cases of HIV transmission to infants and to serodiscordant partners, and proportions of HIV-infected pregnant women with CD4 count of ≤350 cells/mm3 to initiate ART were compared between 2010 Option A and the 2013 recommendations. Total costs of prevention of mother-to-child transmission of HIV (PMTCT) services per annual cohort of pregnant women, incremental cost-effectiveness ratio (ICER) per infection averted and quality-adjusted life-year (QALY) gained were examined. RESULTS: Our analysis suggested that the shift from 2010 Option A to the 2013 guidelines would result in a 33% reduction of the risk of HIV transmission among exposed infants. The risk of transmission to serodiscordant partners for a period of 24 months would be reduced by 72% with 'ARVs during pregnancy and breastfeeding' and further reduced by 15% with 'Lifelong ART'. The probability of HIV-infected pregnant women to initiate ART would increase by 80%. It was also suggested that while the shift would generate higher PMTCT costs, it would be cost-saving in the long term as it spares future treatment costs by preventing infections in infants and partners. CONCLUSION: The shift to the WHO 2013 guidelines in Zambia would positively impact health of family and save future costs related to care and treatment.

The multi-step process of building TB/HIV collaboration in Cambodia.

Tuberculosis and HIV/AIDS have synergistic health impacts in terms of disease development and progression. Therefore, collaborative TB and HIV/AIDS activities are a logical health systems response. However, the establishment of these activities presents a challenge for countries that have strong vertical disease programs that differ in their implementation philosophies. Here, we review the process by which TB/HIV collaboration was established in Cambodia. A cycle of overlapping and mutually reinforcing initiatives - local research; piloted implementation with multiple options; and several rounds of policy formulation guided by a cross-functional Technical Working Group - was used to drive nationwide introduction of a full set of TB/HIV collaborative activities. Senior Ministry of Health officials and partner organizations brought early attention to TB/HIV. Both national programs implemented initial screening and testing interventions, even in the absence of a detailed, overarching framework. The use of multiple options for HIV testing identified which programmatic options worked best, and early implementation and pilots determined what unanswered questions required further research. Local conduct of this research - on co-treatment timing and TB symptom screening - speeded adoption of the results into policy guidance, and clarified the relative roles of the two programs. Roll-out is continuing, and results for a variety of key indicators, including screening PLHIV for TB, and testing TB patients for HIV, are at 70-80% and climbing. This experience in Cambodia illustrates the influence of health research on policy, and demonstrates that clear policy guidance, the pursuit of incremental advances, and the use of different approaches to generate evidence can overcome structural barriers to change and bring direct benefits to patients.

Implementing early-warning indicators of HIV drug resistance in the Caribbean.

A key component of the World Health Organization's (WHO's) Global HIV Drug Resistance (HIVDR) prevention and assessment strategy is to monitor HIVDR early-warning indicators (EWIs), which provide strategic information for HIVDR containment. The Pan American Health Organization (PAHO)/WHO supported implementation of HIVDR EWI monitoring in 16 Caribbean countries. Results from 15 countries were analyzed by year of patient initiation of antiretroviral therapy for the period 2005-2009. This report demonstrates the need for capacity-building to standardize prescribing practices and to strengthen adherence strategies and antiretroviral drug procurement management systems.

Progress of implementation of the World Health Organization strategy for HIV drug resistance control in Latin America and the Caribbean / Progreso en la aplicación de la estrategia de la Organización Mundialde la Salud para el control de la farmacorresistencia del VIH en América Latina y el Caribe

By the end of 2010, Latin America and the Caribbean (LAC) achieved 63% antiretroviral treatment (ART) coverage. Measures to control HIV drug resistance (HIVDR) at the countrylevel are recommended to maximize the efficacy and sustainability of ART programs. Since 2006, the Pan American Health Organization has supported implementation of the WorldHealth Organization (WHO) strategy for HIVDR prevention and assessment through regional capacity-building activities and direct technical cooperation in 30 LAC countries. By 2010, 85 sites in 19 countries reported early warning indicators, providing information about the extent of potential drivers of drug resistance at the ART site. In 2009, 41.9% of sites did notachieve the WHO target of 100% appropriate first-line prescriptions; 6.3% still experienced high rates (> 20%) of loss to follow-up, and 16.2% had low retention of patients (< 70%) on first-line prescriptions in the first year of treatment. Stock-outs of antiretroviral drugs occurred at 22.7% of sites. Haiti, Guyana, and the Mesoamerican region are planning and implementing WHO HIVDR monitoring surveys or threshold surveys. New HIVDR surveillance tools for concentrated epidemics would promote further scale-up. Extending the WHO HIVDR lab network in Latin America is key to strengthening regional lab capacity to support quality assuredHIVDR surveillance. The WHO HIVDR control strategy is feasible and can be rolled out in LAC. Integrating HIVDR activities in national HIV care and treatment plans is key to ensuring the sustainability of this strategy.

Hacia fines del 2010, América Latina y el Caribe lograron una cobertura de tratamiento antirretroviral de 63%. Se recomienda la ejecución de medidas para controlar la farmacorresistencia del VIH a nivel de país para potenciar al máximo la eficacia y la sostenibilidad de los programas de tratamiento antirretroviral. Desde el 2006, la Organización Panamericana de la Salud ha apoyado la aplicación de la estrategia de la Organización Mundial de la Salud (OMS) para la prevención y la evaluación de la farmacorresistenciadel VIH mediante actividades regionales de formación de capacidad y de cooperación técnica directa en 30 países de América Latina y el Caribe. En 2010, 85 centros en 19 países notificaron indicadores de alerta temprana y suministraron información acerca del alcance de los posibles impulsores de la farmacorresistencia enlos centros de tratamiento antirretroviral. En el 2009, 41,9% de los centros no lograron la meta de la OMS de 100% de prescripción de medicamentos de primera línea apropiados; 6,3% todavía tenían tasas elevadas (> 20%) de pérdida de seguimiento y 16,2% tenían una baja retención de pacientes (< 70%) en tratamiento con antirretrovirales deprimera línea en el primer año de tratamiento. Se registraron desabastecimientos de medicamentos antirretrovirales en 22,7% de los centros. Haiti, Guyana y la zona mesoamericana están planificando y ejecutando estudios de vigilancia de la farmacorresistencia del VIH o estudios del umbral de la OMS. Las nuevas herramientas para la vigilancia de la farmacorresistencia del VIH en las epidemias concentradas permitiránuna mejor vigilancia. La ampliación de la red de laboratorios de farmacorresistenciadel VIH acreditados por la OMS en América Latina es fundamental para el fortalecimientode la capacidad de los laboratorios regionales, a fin de de efectuar una vigilancia de la farmacorresistencia del VIH de calidad garantizada...