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addressing geographical disparities and leaving no one behind.World AIDS Day - 1 December
On 29th November, to mark World AIDS Day 2016, WHO launched new guidelines on HIV self-testing to encourage countries to promote self-testing and empower more people to test for HIV. WHO is also launching a new progress report Prevent HIV: test and treat all WHO action for country impact. The report shows that more than 18 million people living with HIV have access to HIV treatment, but many more lack HIV diagnosis and consequently are missing out on treatment.
The global HIV epidemic claimed fewer lives in 2015 than at any point in almost twenty years. Prevention programmes reduced the number of new HIV infections per year to 2.1 million in 2015, a 35% decline in incidence since 2000. The massive expansion of antiretroviral therapy has reduced the number of people dying of HIV related causes to approximately 1.1 million 2015 45% fewer than in 2005.
Having achieved the global target of halting and reversing the spread of HIV, world leaders have set the 2020 Fast-Track targets to accelerate the HIV response and to END AIDS BY 2030.
On World AIDS Day 2016, WHO will be promoting these new innovative HIV testing policies, urging countries and communities deploy high-impact prevention services, and further expand early and quality treatment for all, addressing geographical disparities and leaving no one behind.
The Human Immuno-deficiency Virus (HIV) targets the immune system and weakens peoples defence systems against infections and some types of cancer. As the virus destroys and impairs the function of immune cells, infected individuals gradually become immunodeficient. Immune function is typically measured by CD4 cell count. Immunodeficiency results in increased susceptibility to a wide range of infections, cancers and other diseases that people with healthy immune systems can fight off.
The most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the individual. AIDS is defined by the development of certain cancers, infections, or other severe clinical manifestations.
Signs and symptoms
The symptoms of HIV vary depending on the stage of infection. Though people living with HIV tend to be most infectious in the first few months, many are unaware of their status until later stages. The first few weeks after initial infection, individuals may experience no symptoms or an influenza-like illness including fever, headache, rash or sore throat.
As the infection progressively weakens the immune system, an individual can develop other signs and symptoms, such as swollen lymph nodes, weight loss, fever, diarrhoea and cough. Without treatment, they could also develop severe illnesses such as tuberculosis, cryptococcal meningitis, and cancers such as lymphomas and Kaposis sarcoma, among others.
Transmission
HIV can be transmitted via the exchange of a variety of body fluids from infected individuals, such as blood, breast milk, semen and vaginal secretions. Individuals cannot become infected through ordinary day-to-day contact such as kissing, hugging, shaking hands, or sharing personal objects, food or water.
Risk factors
Behaviours and conditions that put individuals at greater risk of contracting HIV include:
having unprotected anal or vaginal sex;
having another sexually transmitted infection such as syphilis, herpes, chlamydia, gonorrhoea, and bacterial vaginosis;
sharing contaminated needles, syringes and other injecting equipment and drug solutions when injecting drugs;
receiving unsafe injections, blood transfusions, tissue transplantation, medical procedures that involve unsterile cutting or piercing; and
experiencing accidental needle stick injuries, including among health workers.
Diagnosis
Serological tests, such as RDTs or enzyme immunoassays (EIAs), detect the presence or absence of antibodies to HIV-1/2 and/or HIV p24 antigen. When such tests are used within a testing strategy according to a validated testing algorithm, HIV infection can be detected with great accuracy. It is important to note that serological tests detect antibodies produced by an individual as part of their immune system to fight off foreign pathogens, rather than direct detection of HIV itself.
Most individuals develop antibodies to HIV-1/2 within 28 days and therefore antibodies may not be detectable early after infection, the so-called window period. This early period of infection represents the time of greatest infectivity; however HIV transmission can occur during all stages of the infection.
It is best practice to also retest all people initially diagnosed as HIV-positive before they enrol in care and/or treatment to rule out any potential testing or reporting error.
HIV testing services
HIV testing should be voluntary and the right to decline testing should be recognized. Mandatory or coerced testing by a health-care provider, authority or by a partner or family member is not acceptable as it undermines good public health practice and infringes on human rights.
Some countries have introduced, or are considering, self-testing as an additional option. HIV self-testing is a process whereby a person who wants to know his or her HIV status collects a specimen, performs a test and interprets the test results in private.
HIV self-testing does not provide a definitive diagnosis; instead, it is an initial test which requires further testing by a health worker using a nationally validated testing algorithm.
All HIV testing services must include the 5 Cs recommended by WHO: informed Consent, Confidentiality, Counselling, Correct test results and Connection (linkage to care, treatment and other services).
Prevention
Individuals can reduce the risk of HIV infection by limiting exposure to risk factors. Key approaches for HIV prevention, which are often used in combination, include:
1. Male and female condom use
Correct and consistent use of male and female condoms during vaginal or anal penetration can protect against the spread of sexually transmitted infections, including HIV. Evidence shows that male latex condoms have an 85% or greater protective effect against HIV and other sexually transmitted infections (STIs).
2. Testing and counselling for HIV and STIs
Testing for HIV and other STIs is strongly advised for all people exposed to any of the risk factors. This way people learn of their own infection status and access necessary prevention and treatment services without delay. WHO also recommends offering testing for partners or couples. Additionally, WHO is recommending assisted partner notification approaches so that people with HIV receive support to inform their partners either on their own, or with the help of health care providers.
3. Testing and counselling, linkages to tuberculosis care
Tuberculosis (TB) is the most common presenting illness and cause of death among people with HIV. It is fatal if undetected or untreated and is the leading cause of death among people with HIV- responsible for 1 of every 3 HIV-associated deaths. Early detection of TB and prompt linkage to TB treatment and ART can prevent these deaths. TB screening should be offered routinely at HIV care services. Individuals who are diagnosed with HIV and active TB should be urgently started on TB treatment and ART. TB preventive therapy should be offered to people with HIV who do not have active TB.
4. Voluntary medical male circumcision
Medical male circumcision, when safely provided by well-trained health professionals, reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. This is a key intervention supported in 14 countries in Eastern and Southern Africa with high HIV prevalence and low male circumcision rates.
5. Antiretroviral (ARV) drug use for prevention
5.1 Prevention benefits of ART
A 2011 trial has confirmed if an HIV-positive person adheres to an effective ART regimen, the risk of transmitting the virus to their uninfected sexual partner can be reduced by 96%. The WHO recommendation to initiate ART in all people living with HIV will contribute significantly to reducing HIV transmission.
5.2 Pre-exposure prophylaxis (PrEP) for HIV-negative partner
Oral PrEP of HIV is the daily use of ARV drugs by HIV-uninfected people to block the acquisition of HIV. More than 10 randomized controlled studies have demonstrated the effectiveness of PrEP in reducing HIV transmission among a range of populations including serodiscordant heterosexual couples (where one partner is infected and the other is not), men who have sex with men, transgender women, high-risk heterosexual couples, and people who inject drugs.
WHO recommends PrEP as a prevention choice for people at substantial risk of HIV infection as part of combination prevention approaches.
5.3 Post-exposure prophylaxis for HIV (PEP)
Post-exposure prophylaxis (PEP) is the use of ARV drugs within 72 hours of exposure to HIV in order to prevent infection. PEP includes counselling, first aid care, HIV testing, and administering of a 28-day course of ARV drugs with follow-up care. WHO recommendsPEP use for both occupational and non-occupational exposures and for adults and children.
6. Harm reduction for injecting drug users
People who inject drugs can take precautions against becoming infected with HIV by using sterile injecting equipment, including needles and syringes, for each injection and not sharing other drug using equipment and drug solutions. A comprehensive package of interventions for HIV prevention and treatment includes:
needle and syringe programmes;
opioid substitution therapy for people dependent on opioids and other evidence based drug dependence treatment;
HIV testing and counselling;
risk-reduction information and education;
HIV treatment and care;
access to condoms; and
management of STIs, tuberculosis and viral hepatitis.
7. Elimination of mother-to-child transmission of HIV (EMTCT)
The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called vertical or mother-to-child transmission (MTCT).
In the absence of any interventions during these stages, rates of HIV transmission from mother-to-child can be between 15-45%. MTCT can be nearly fully prevented if both the mother and the child are provided with ARV drugs throughout the stages when infection could occur.
WHO recommends options for prevention of MTCT (PMTCT), which includes providing ARVs to mothers and infants during pregnancy, labour and the post-natal period, and offering life-long treatment to HIV-positive pregnant women regardless of their CD4 count.
In 2015, 77% (6986%) of the estimated 1.4 (1.3-1.6) million pregnant women living with HIV globally received effective ARV drugs to avoid transmission to their children. A growing number of countries are achieving very low rates of MTCT and some (Armenia, Belarus, Cuba and Thailand) have been formally validated for elimination of MTCT of HIV. Several countries with a high burden of HIV infection are closing in on that goal.
Treatment
HIV can be suppressed by combination ART consisting of 3 or more ARV drugs. ART does not cure HIV infection but controls viral replication within a persons body and allows an individuals immune system to strengthen and regain the capacity to fight off infections.
In 2016, WHO released the second edition of the Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. These guidelines present several new recommendations, including the recommendation to provide lifelong ART to all children, adolescents and adults, including all pregnant and breastfeeding women living with HIV, regardless of CD4 cell count.
WHO has also expanded earlier recommendations to offer PrEP to selected people at substantial risk of acquiring HIV. Alternative first-line treatment regimens are recommended, including an integrase inhibitor as an option in resource-limited settings and reduced dosage of a key recommended first-line drug, efavirenz, to improve tolerability and reduce costs. By mid-2016, 18.2.0 million people living with HIV were receiving ART globally which meant a global coverage of 46% (4350%).
Based on WHOs new recommendations, to treat all people living with HIV and offer antiretroviral drugs as an additional prevention choice for people at substantial risk, the number of people eligible for antiretroviral treatment increases from 28 million to all 36.7 million people. Expanding access to treatment is at the heart of a new set of targets for 2020 which aim to end the AIDS epidemic by 2030.
WHO response
The Sixty-ninth World Health Assembly endorsed a new Global Health Sector Strategy on HIV for 2016-2021. The strategy includes 5 strategic directions that guide priority actions by countries and by WHO over the next six years.
The strategic directions are:
Information for focused action (know your epidemic and response).
Interventions for impact
(covering the range of services needed)
Delivering for equity (covering the populations in need of
services).
Financing for sustainability (covering the costs of services).
Innovation for acceleration (looking towards the future).
WHO is a cosponsor of the Joint United Nations Programme on AIDS (UNAIDS). Within UNAIDS, WHO leads activities on HIV treatment and care, HIV and tuberculosis co-infection, and jointly coordinates with UNICEF the work on the elimination of mother-to-child transmission of HIV.
Source: WHO
