HIV This Week

HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.

Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B, Ambekar A, Strathdee SA; for the 2009 Reference Group to the UN on HIV and Injecting Drug Use. Lancet. 2010; 375:1014-28

Previous reviews have examined the existence of HIV prevention, treatment, and care services for persons who inject drugs worldwide, but they did not quantify the scale of coverage. Mathers and colleagues undertook a systematic review to estimate national, regional, and global coverage of HIV services in people who inject drugs. The authors did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for persons who inject drugs: needle and syringe programmes, opioid substitution therapy and other drug treatment, HIV testing and counselling, antiretroviral therapy, and condom programmes. They calculated national, regional, and global coverage of needle and syringe programmes, opioid substitution therapy, and antiretroviral therapy on the basis of available estimates of persons who inject drugs population sizes. By 2009, needle and syringe programmes had been implemented in 82 countries and opioid substitution therapy in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per individuals who inject drugs per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per individuals who inject drugs per year), Middle East and north Africa (0.5 needle-syringes per individuals who inject drugs per year), and sub-Saharan Africa (0.1 needle-syringes per individuals who inject drugs per year) had the lowest rates. Opioid substitution therapy  coverage varied from less than or equal to one recipient per 100 persons who inject drugs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100  individuals who inject drugs). The number of persons who inject drugs receiving antiretroviral therapy varied from less than one per 100 HIV-positive persons who inject drugs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive persons who inject drugs in six European countries. Worldwide, an estimated  two needle-syringes (range 1-4) were distributed per persons who inject drugs per month, there were eight recipients (6-12) of opioid substitution therapy per 100 persons who inject drugs, and four persons who inject drugs (range 2-18) received  antiretroviral therapy per 100 HIV-positive persons who inject drugs. Worldwide coverage of HIV prevention, treatment, and care services in persons who inject drugs populations is very low. There is an urgent need to improve coverage of these services in this population at higher risk from HIV. 

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Editor’s note: Although the number of countries with core HIV prevention services (needle-syringe programmes [NSP], opioid substitution therapy [OST], and antiretroviral therapy[ART]) for people who inject drugs is growing, coverage is highly variable and it remains very poor in the majority of countries. Outside of sub-Saharan Africa, one-third of all HIV infections are acquired through injecting with contaminated equipment. Unless there is concerted action to address the risk environments that decrease the likelihood that sterile injecting equipment can be used, HIV transmission through injecting will continue to flourish. Rapid expansion of coverage for the 9 core interventions identified as essential by UNODC, WHO, and UNAIDS is urgently needed. In addition to NSP, OST, and ART, these are voluntary counselling and testing; prevention and treatment of sexually transmitted infections; condom programming for injecting drug users and partners; tailored information, education and communication; vaccination, diagnosis, and treatment of viral hepatitis; and prevention, diagnosis, and treatment of tuberculosis. New interventions are not needed, rather policies to increase implementation of proven HIV programmes clearly are – and that will require that policy-makers recognise that it is high time for rights-based, evidence-informed policies and programming.

The UNITAID Patent Pool Initiative: Bringing Patents Together for the Common Good.

Bermudez J, 't Hoen E. Open AIDS J. 2010;4:37-40.

Developing and delivering appropriate, affordable, well-adapted medicines for HIV remains an urgent challenge: as first-line therapies fail, increasing numbers of people require costly second-line therapy; one-third of antiretrovirals are not available in paediatric formulations; and certain key first- and second-line triple fixed-dose combinations do not exist or sufficient suppliers are lacking.  UNITAID aims to help solve these problems through an innovative initiative for the collective management of intellectual property rights - a patent pool for HIV medicines. The idea behind a patent pool is that patent holders - companies, governments, researchers or universities - voluntarily offer, under certain conditions, the intellectual property related to their inventions to the patent pool. Any company that wants to use the intellectual property to produce or develop medicines can seek a license from the pool against the payment of royalties, and may then produce the medicines for use in developing countries (conditional upon meeting agreed quality standards). The patent pool will be a voluntary mechanism, meaning its success will largely depend on the willingness of pharmaceutical companies to participate and commit their intellectual property to the pool. Generic producers must also be willing to cooperate. The pool has the potential to provide benefits to all.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842943/

Editors’ note: UNITAID, launched at the UN General Assembly in September 2006 by Brazil, Chile, France, Norway, and the United Kingdom, is an innovative financing mechanism that has expanded to include more than 29 countries and the Bill and Melinda Gates Foundation. Some are providing multi-year budgetary contributions while others have placed a solidarity tax on airline tickets. A full plane from Paris to New York raises enough money to cover a year of antiretroviral treatment for 60 HIV-positive children. In addition to dedicating at least 85% of its spending on products for low-income countries, UNITAID is committed to a pro-health approach to intellectual property. The concept of patent pools is very timely now. Fixed dose combinations of the new WHO recommended first line of tenofovir, lamivudine, and nevirapine or efavirenz, do not exist or are limited in supply. Affordable second line drugs are urgently needed for patients failing first line therapy and a third of antiretroviral drugs are not available in paediatric formulation. Patent terms are normally 20 years. Patent pools have worked, for example, in agriculture, aeronautics, and information technology when relevant patents for a process are owned by many different entities. They reward pharmaceutical companies for their investment in research and development, give them a reputational boost, reduce transaction costs associated with negotiating individual license and price reductions, and avert the risk of compulsory licensing of their products. Patent pools provide generic companies access to intellectual property more easily and quickly and they ensure faster access to better, more affordable antiretroviral treatment for patients in low-income countries. Under the World Trade Organisation (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), governments can and do override patents to meet public health needs. However, a less complex and more timely process would be a voluntary patent pool. It is time to step up to the plate!

Amon JJ, Kasambala T. Structural barriers and human rights related to HIV prevention and treatment in Zimbabwe. Glob Public Health. 2009 Mar 26:1-17. [Epub ahead of print]

There has long been recognition that individual risk factors can only partially explain vulnerability to HIV infection, and that a broader range of socioeconomic, cultural and political factors must be taken into account. More recently this understanding has been applied to addressing obstacles to accessing HIV treatment. Yet, while structural interventions aimed at contextual factors related to HIV prevention and treatment have been shown to be effective, they have not been widely implemented. Using the situation of Zimbabwe as an example, Amon and Kasambala present an illustration of how contextual barriers can be understood in human rights terms, and how using a human rights analysis can specifically help define ‘structural-rights’ interventions and compel their implementation.

Editors’ note: This article, a must-read for all those interested in effective combination prevention, demonstrates how explicitly recognising human rights provides a mechanism to address structural level barriers to HIV prevention and care, reinforcing government and donor agency accountability to redress societal power differentials. In other words, situating concerns about the socioeconomic, cultural, and political barriers to HIV prevention within a context of human rights provides a framework for action founded on the obligations and responsibilities of states. Drawing on the current HIV and human rights crisis in Zimbabwe, specific examples are provided of concrete structural-rights interventions to address the right to earn a livelihood and own property; the right to freedom of expression, assembly, and information; the right to freedom from gender-based and sexual violence; and the right to the progressive realisation of health.

Calmy A, Pizzocolo C, Pizarro L, Brücker G, Murphy R, Katlama C; Strategies in Resource-Limited Settings Working Group. The marriage of science and optimized HIV care in resource-limited settings. AIDS. 2008;22(17):2227-30.

Large-scale HIV management in resource-limited settings has been remarkably successful in a relatively short time frame. Once combination antiretroviral therapy became more universally available, national treatment programs were able to provide much of the needed therapy, originally prioritized towards patients with the most advanced and symptomatic disease. The current worldwide expansion of antiretroviral therapy is due to a large broad-based international effort in financing the antiretroviral drugs and infrastructure required for delivering treatment and care. The fears that HIV treatment would detract from other healthcare concerns or lead to widespread drug resistance have been unfounded but important treatment-related issues remain to be addressed immediately by relevant scientific communities. The fundamental scientific concerns fall into two categories: the comprehensive approach to care and treatment management in settings in which resources are limited, and the diversity of a variety of populations who are predominantly women, have heterogeneous viral subtypes and have exposure to different environmental co-pathogens. There is an urgent need to link science and clinical practice wherever it is taking place. We need to learn more about optimal treatment choices and monitoring schemes appropriate in diverse resource-limited settings. Relevant clinical data that are urgently needed include drug efficacy in genetically diverse populations, the most cost-effective and efficient monitoring of therapy, and interactions with drugs to treat common co-infections and diseases. Transfer of competencies must be done as this is essential for operational research. In addition, we must promote and strengthen national reference centres and develop high level skills for the next generation of scientists and clinicians. The international scientific community must address this urgent need with academic, social, scientific, and economic support for the necessary critical research and training so desperately needed.

Editors’ note: This is an urgent call for more science, more science capacity-building, and more operational research competencies transfer to enable clinical data collection, monitoring, analysis, and evaluation at the service of improved care. Key questions to address include how to improve adherence, when to switch therapies, optimal treatment for pregnant women, and important drug-drug interactions with anti-tuberculosis and anti-malarial agents.