The 90 90 90 strategy to end the HIV Pandemic by 2030: Can the supply chain handle it?

INTRODUCTION: UNAIDS "90-90-90" strategy calls for 90% of HIV-infected individuals to be diagnosed by 2020, 90% of whom will be on anti-retroviral therapy (ART) and 90% of whom will achieve sustained virologic suppression. Reaching these targets by 2020 will reduce the HIV epidemic to a low-level endemic disease by 2030. However, moving the global response towards this universal test and treat model will pose huge challenges to public health systems in resource-limited settings, including global and local supply chain systems. These challenges are especially acute in Africa, which accounts for over 70% of the persons affected by HIV. DISCUSSION: From a supply chain perspective, each of the "90's" has possible complications and roadblocks towards realizing the promise envisioned by 90-90-90. For instance, ensuring that 90% of HIV-infected persons know their status will require a large increase in access to HIV tests compared with what is currently available. To ensure that there are enough anti-retrovirals available to treat the nearly 25 million people that will require them by 2020 represents a near doubling of the ARV supplied to treat the 13 million currently on treatment. Similarly, to monitor those on treatment means an unprecedented scale-up of viral load testing throughout Africa. CONCLUSIONS: Larger issues include whether the capacity exists at the local level to handle these commodities when they arrive in the most severely affected countries, including considerations of the human resources and costs needed to make this strategy effective. We believe that such "real world" analysis of proposed strategies and policies is essential to ensure their most effective implementation.

Evaluating the impact of prevention of mother-to-child transmission of HIV in Malawi through immunization clinic-based surveillance.

BACKGROUND: Prevention of mother-to-child transmission of HIV (PMTCT) programs can greatly reduce the vertical transmission rate (VTR) of HIV, and Malawi is expanding PMTCT access by offering HIV-infected pregnant women life-long antiretroviral therapy (Option B+). There is currently no empirical data on the effectiveness of Malawian PMTCT programs. This study describes a surveillance approach to obtain population-based estimates of the VTR of infants <3 months of age in Malawi immediately after the adoption of Option B+. METHODS AND FINDINGS: A sample of caregivers and infants <3 months from 53 randomly chosen immunization clinics in 4 districts were enrolled. Infant dried blood spot (DBS) samples were tested for HIV exposure with an antibody test to determine maternal seropositivity. Positive samples were further tested using DNA PCR to determine infant infection status and VTR. Caregivers were surveyed about maternal receipt of PMTCT services. Of the 5,068 DBS samples, 764 were ELISA positive indicating 15.1% (14.1-16.1%) of mothers were HIV-infected and passed antibodies to their infant. Sixty-five of the ELISA-positive samples tested positive by DNA PCR, indicating a vertical transmission rate of 8.5% (6.6-10.7%). Survey data indicates 64.8% of HIV-infected mothers and 46.9% of HIV-exposed infants received some form of antiretroviral prophylaxis. Results do not include the entire breastfeeding period which extends to almost 2 years in Malawi. CONCLUSIONS: The observed VTR was lower than expected given earlier modeled estimates, suggesting that Malawi's PMTCT program has been successful at averting perinatal HIV transmission. Challenges to full implementation of PMTCT remain, particularly around low reported antiretroviral prophylaxis. This approach is a useful surveillance tool to assess changes in PMTCT effectiveness as Option B+ is scaled-up, and can be expanded to track programming effectiveness for young infants over time in Malawi and elsewhere.

Beyond prevention of mother-to-child transmission: keeping HIV-exposed and HIV-positive children healthy and alive.

In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015. This increased focus on the elimination of maternal to child transmission (MTCT) is most welcome but is insufficient, as access to prevention of MTCT (PMTCT) programming is neither uniform nor universal. A new and more expansive agenda must be articulated to ensure that those infants and children who will never feel the impact of the current elimination agenda are reached and linked to appropriate care and treatment. This agenda must addresses challenges around both reducing vertical transmission through PMTCT and ensuring access to appropriate HIV testing, care, and treatment for all affected children who were never able to access PMTCT programming. Option B+, or universal test and treat for HIV-infected pregnant women is an excellent start, but it may be time to rethink our current approaches to delivering PMTCT services. New strategies will reduce vertical transmission to less than 1% for those mother-infant pairs who can access them allowing for the contemplation of not just PMTCT, but actual elimination of MTCT. But expanded thinking is needed to ensure elimination of pediatric HIV.

Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children.

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

Delivering pediatric HIV care in resource-limited settings: cost considerations in an expanded response.

If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.

Understanding the contribution of common childhood illnesses and opportunistic infections to morbidity and mortality in children living with HIV in resource-limited settings.

OBJECTIVE: Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration. DESIGN AND METHODS: Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience. RESULTS: Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent. CONCLUSIONS: In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.

HIV-exposed infants: rethinking care for a lifelong condition.

Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210 000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother-infant pairs.

Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview.

In 2012, there were an estimated 2 million children in need of antiretroviral therapy (ART) in the world, but ART is still reaching fewer than 3 in 10 children in need of treatment. [1, 7] As more HIV-infected children are identified early and universal treatment is initiated in children under 5 regardless of CD4, the success of pediatric HIV programs will depend on our ability to link children into care and treatment programs, and retain them in those services over time. In this review, we summarize key individual, institutional, and systems barriers to diagnosing children with HIV, linking them to care and treatment, and reducing loss to follow-up (LTFU). We also explore how linkage and retention can be optimally measured so as to maximize the impact of available pediatric HIV care and treatment services.

Pediatric treatment 2.0: ensuring a holistic response to caring for HIV-exposed and infected children.

Treatment 2.0 is an initiative launched by UNAIDS and WHO in 2011 to catalyze the next phase of treatment scale-up for HIV. The initiative defines strategic activities in 5 key areas, drugs, diagnostics, commodity costs, service delivery and community engagement in an effort to simplify treatment, expand access and maximize program efficiency. For adults, many of these activities have already been turned into treatment policies. The recent WHO recommendation to use a universal first line regimen regardless of gender, pregnancy and TB status is a treatment simplification very much in line with Treatment 2.0. But despite that fact that Treatment 2.0 encompasses all people living with HIV, we have not seen the same evolution in policy development for children. In this paper we discuss how Treatment 2.0 principles can be adapted for the pediatric population. There are several intrinsic challenges. The need for distinct treatment regimens in children of different ages makes it hard to define a one size fits all approach. In addition, the fact that many providers are reluctant to treat children without the advice of specialists can hamper decentralization of service delivery. But at the same time, there are opportunities that can be availed now and in the future to scale up pediatric treatment along the lines of Treatment 2.0. We examine each of the five pillars of Treatment 2.0 from a pediatric perspective and present eight specific action points that would result in simplification of pediatric treatment and scale up of HIV services for children.

The free condom initiative: promoting condom availability and use in New York City.

In 2005, the New York City Department of Health and Mental Hygiene (DOHMH) made free condoms available to organizations through a Web-based ordering system. In 2006, we interviewed managers and patrons about free condom availability, acquisition, and use in venues where people at high risk for human immunodeficiency virus congregate. DOHMH condom distribution increased from 5.8 million in 2004 to 17.3 million in 2006. Overall, managers reported making condoms available at 76% (309/409) of high-priority venues, but only at 40% of gay bars. Among patrons who saw free condoms, 80% (280/351) reported taking them; 73% (205/280) of those who reported taking them also reported using them. A simple, Web-based ordering system dramatically increased condom distribution. In the venues we sampled, the majority of patrons acquired and used free condoms when available and visible, suggesting that increasing free condom availability may increase use. Special efforts are needed to ensure availability at gay bars.

Population prevalence of reported and unreported HIV and related behaviors among the household adult population in New York City, 2004.

BACKGROUND: Surveillance for HIV likely underestimates infection among the general population: 25% of US residents are estimated to be unaware of their HIV infection. OBJECTIVE: To determine the prevalence of HIV infection and risk behaviors among New York City (NYC) adults and compare these with surveillance findings. METHODS: The NYC Health and Nutrition Examination Survey (HANES) provided the first opportunity to estimate population-based HIV prevalence among NYC adults. It was conducted in 2004 among a representative sample of adults > 20 years. Previously reported HIV infection was identified from the NYC HIV/AIDS Surveillance Registry. A blinded HIV serosurvey was conducted on archived blood samples of 1626 NYC HANES participants. Data were used to estimate prevalence for HIV infection, unreported infections, high-risk activities, and self-perceived risk. RESULTS: Overall, 18.1% engaged in one or more risky sexual/needle-use behaviors, of which 92.2% considered themselves at low or no risk of HIV or another sexually transmitted disease. HIV occurred in 21 individuals (prevalence 1.4%; 95% confidence interval (CI), 0.8-2.5]; one infection (5%; 95% CI, 0.7-29.9) was not reported previously and possibly undiagnosed. HIV infection was significantly elevated in those with herpes simplex virus 2 (4%), men who have sex with men (14%), and needle-users (21%) (P < 0.01). CONCLUSIONS: Among NYC adults, HIV prevalence was consistent with surveillance findings overall. The proportion of unreported HIV was less than estimated nationally, but findings were limited by sample size. Most adults with risky behaviors perceived themselves to be at minimal risk, highlighting the need for risk reduction and routine HIV screening.

The economic burden of HIV in the United States in the era of highly active antiretroviral therapy: evidence of continuing racial and ethnic differences.

BACKGROUND: Assessing the economic burden of HIV/AIDS can help to quantify the effect of the epidemic on a population and assist policy makers in allocating public health resources. OBJECTIVE: To estimate the economic burden of HIV/AIDS in the United States and provide race/ethnicity-specific estimates. METHODS: We conducted an incidence-based cost-of-illness analysis to estimate the lifetime cost of HIV/AIDS resulting from new infections diagnosed in 2002. Data from the HIV/AIDS Reporting System of the Centers for Disease Control and Prevention were used to determine stage of disease at diagnosis and proportion of cases by race/ethnicity. Lifetime direct medical costs and mortality-related productivity losses were estimated using data on cost, life expectancy, and antiretroviral therapy (ART) use from the literature. RESULTS: The cost of new HIV infections in the United States in 2002 is estimated at $36.4 billion, including $6.7 billion in direct medical costs and $29.7 billion in productivity losses. Direct medical costs per case were highest for whites ($180,900) and lowest for blacks ($160,400). Productivity losses per case were lowest for whites ($661,100) and highest for Hispanics ($838,000). In a sensitivity analysis, universal use of ART and more effective ART regimens decreased the overall cost of illness. CONCLUSION: Direct medical costs and productivity losses of HIV/AIDS resulting from infections diagnosed in 2002 are substantial. Productivity losses far surpass direct medical costs and are disproportionately borne by minority races/ethnicities. Our analysis underscores economic benefits of more effective ART regimens and universal access to ART.

Use of and exposure to HIV prevention programs and services by persons at high risk for HIV.

Although HIV information is widely available in this country, little is known about how commonly used HIV prevention activities reach persons at highest risk for HIV. In this paper, we describe the extent to which HIV prevention strategies reach a sample of high-risk persons and whether such exposure correlates with having been tested for HIV. Data are from the 2000 HIV Testing Survey, an anonymous interview study of men who have sex with men (MSM), injection drug users (IDU), and high-risk heterosexuals (HRH), recruited from appropriate venues in seven states and New York City. We report the proportion of persons exposed to three types of interventions: information (media messages, brochures), counseling or skills-building (group counseling, role play, calling an AIDS hotline), and prevention supplies (provision of condoms, bleach kits), stratified by HIV testing status (ever, never). Exposure to information interventions was high among 2491 respondents (85%-96%) and did not differ by testing status. Use of counseling or skills-building interventions varied by testing status for IDU (8% untested versus 41% tested, p < 0.01) and HRH (14% versus 20%, p = 0.03) but not MSM (15% versus 23%, p = 0.08). Among tested IDU, those receiving bleach kits were more likely to report consistent bleach use when injecting with nonsterile needles (25% versus 9%, p = 0.003). Exposure to HIV prevention information is high but exposure to counseling or skills-building interventions is less common and more prevalent among those previously tested. Prevention initiatives should focus on counseling and testing, skills-building, and prevention supplies.