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Not Enough Is Being Done to Provide Universal Access to HIV Treatment, Advocates Say


An international coalition of AIDS treatment advocates, clinical providers, and people living with HIV has released an analysis showing than fewer than 1 in 10 people with HIV live in countries that provide antiretroviral therapy (ART) for all regardless of CD4 count, contrary to international treatment guidelines. The activists urged more funding to make global recommendations for universal treatment a reality.

Ahead of World AIDS Day on December 1, the World Health Organization (WHO) issued the finalized version of its Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. WHO previously released a preliminary version in September.

The guidelines recommend antiretroviral treatmentfor everyone diagnosed with HIV regardless of CD4 T-cell count or clinical symptoms, and recommend pre-exposure prophylaxis (PrEP) for people at substantial risk of infection.The recommendations were influenced by a growing body of evidence, including findings from the large START and HPTN 052 trials, showing that starting treatment soon after diagnosis significantly lowers the risk of disease progression and death, as well as reducing HIV transmission.

U.S. Department of Health and Human Services guidelines began recommending treatment for everyone diagnosed with HIV in 2012. The European AIDS Clinical Society (EACS) released guidelines calling for universal treatment at its recent conference in Barcelona, bring major national guidelines in high-income countries and the WHO global guidelines into agreement for the first time since 2006.

But that agreement is not yet being put into practice, according to a report -- Towards Treatment on Demand for All -- prepared and endorsed by Health GAP and a global coalition of partners including the International Association of Providers of AIDS Care, International Community of Women Living with HIV, Pangea, the Treatment Action Campaign, and regional organizations from Africa, Asia, and Latin America and the Caribbean.

The report, released on November 30, shows that only 9% of people with HIV live in countries that offer treatment to everyone immediately upon diagnosis. Those who do not are often sent home from clinics after an HIV diagnosis because their CD4 count is still too high, only to come back once they are sick enough to be eligible for treatment.

"The indefensible reality is that most people diagnosed with HIV are turned away from treatment and told to come back when they’re sicker. Said Health GAP executive director Asia Russell. "But in many rich countries, people living with HIV can access treatment no matter their stage of disease. This deadly double standard must end."

According to UNAIDS, 15.8 million of the estimated 36.9 million people living with HIV worldwide had access to antiretroviral treatment by June 2015, leaving approximately 21.1 million eligible but untreated.

The 13 countries that do offer immediate "treatment on demand" to everyone diagnosed with HIV are all high-income or upper middle-income countries that together represent just 4.4% of the global burden of AIDS-related mortality, the report says. The average per capita annual income in these 13 countries is $29,388, compared to just $9,003 in the 20 countries that account for approximately 80% of global HIV disease burden.

Of the 114 countries with published HIV treatment guidelines, 55 are "severely out of compliance," according to the report, with a treatment initiation threshold lower than even the previous WHO level of 500 cells/mm3. Some do not call for ART until a person's CD4 count falls below 350 or even 200 cells/mm3, indicating serious immune system damage and elevated risk of opportunistic illnesses.

"Delay in implementing test-and-treat translates into millions of avoidable deaths and new HIV infections," said José Zuniga, president of the International Association of Providers of AIDS Care. "And, while the numbers are breathtaking, each death represents an unnecessary tragedy that has devastating effects at individual, family, and community level. We have a moral obligation to ensure that everyone has access to the highest standard of HIV care no matter where they happen to be born or live."

The report endorsers demand that all countries should adopt policies allowing everyone living with HIV to access treatment on demand, and call on donor countries to commit to providing the necessary funding before the United Nations High Level Meeting on AIDS in June 2016. They stressed that countries should use flexibilities in intellectual property rules to ensure that generic HIV drugs are available and affordable, and add that countries must address human rights barriers to expanded access to care, including HIV criminalization, stigma, and discrimination.

The advocates added that they are committed to holding donor and implementing countries accountable at the 21st International AIDS Conference in Durban in July.

"We are long overdue for a reality check in the global AIDS response," said Anele Yawa, general secretary of the South African Treatment Action Campaign. "No matter how much people talk about an 'end to AIDS,' as long as the political will is not there to fix healthcare systems and to increase investment then an 'end to AIDS' will remain a pipedream and the people on the ground will continue to suffer."

Another advocacy organization, the ONE Campaign, also issued a report for World AIDS Day, warning of an estimated $12 billion annual shortfall in the amount needed to halt the epidemic. Current global HIV/AIDS spending was estimated at $20 billion in 2014, but must reach $32 billion by 2020 to "bend the curve of the disease toward the end of the epidemic."

ONE also called attention to social, economic, and legal barriers in many countries that make men who have sex with men, transgender people, and adolescent women and girls more vulnerable to becoming infected with HIV and less likely to seek testing and treatment.

"The progress we’ve made against HIV/AIDS is so powerful that it’s easy to get lulled into a false sense of security about the size of the fight in front of us," said ONE director of global health policy Erin Hohlfelder. "The world is still nearly $12 billion short annually of what it will take to end this disease, and those missing dollars, euros, pounds, naira, and yen won’t grow on trees. This World AIDS Day -- with the trajectory of the epidemic and millions of lives at stake -- we need governments, companies, and philanthropists to step up and provide the resources needed to stop AIDS in its tracks."



Health GAP and partners. Towards Treatment on Demand for All. December 2015.

Health GAP and partners. Fewer Than 1 in 10 People Living with HIV Live in a Country Following Current HIV Treatment Science. Press release. November 30, 2015.

ONE Campaign. New ONE report sounds the alarm about government complacency in global fight against HIV/AIDS. Press release. December 1, 2015.