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The 3 by 5 initiative

The 3 by 5 initiative set up by the WHO and UNAIDS aimed to have 3 million people on antiretroviral therapy (ART) by 2005. During 2004, a commitment was made in the region to provide 70,000 people with ART. Efforts focused on scaling up treatment access, providing technical support, capacity building, procurement, guideline management, etc, to countries that officially declared interest in participation: Somalia, Egypt, Sudan, Djibouti, Yemen, Somalia, Libya and the Islamic Republic of Iran.[1] Although the goals were not met by 2005, the 3 by 5 initiative was the catalyst in mobilizing partners in the region to resolutely continue and endeavour to meet the new global deadline in 2010.

A brief overview in MENA

It is estimated that 35 000 people were infected with HIV in the region in 2007, bringing the total to 380 000 people living with HIV and 25 000 dying of HIV-related illness.[2] Access to treatment is variable and inconsistent, although provision is primarily through the health sector and free-of-charge. Access is often hindered by poor procurement and lack of second-line antiretroviral drugs (required in failure of initial treatment) in some countries. There is a stark deficit between those needing and receiving treatment throughout. Less than 10% of the estimated number of adults requiring ART was reported to have had treatment in the Islamic Republic of Iran, Sudan and Somalia in 2006. In Lebanon, Saudi Arabia, Libya, Tunisia and Morocco more than 40% received treatment but their prevalence is decidedly lower. Yemen and Afghanistan did not report to provide any treatment.[3]

Treatment is comprehensive in nature on two fronts. It involves antiretroviral therapies, prophylactic treatment for infections, nutrition and complementary therapies as well holistic approaches in care and support. It is also comprehensive in that it involves formal and informal medical services, governments, people living with HIV, families and the wider community.  This section discusses accessibility, ART, nutrition and complementary therapies and opportunistic infections.

Strategies to increase accessibility to treatment

Awareness of one’s HIV status

It stands to reason that one of the prerequisites to receiving treatment is awareness of one’s status. The existence of Voluntary Counselling and Testing centres (VCT) is the most effective method of testing for HIV. The VCT approach instils the minimum standards of obtaining consent, ensuring confidentiality and offering counselling. Counselling should be adapted to the needs of the individuals – culturally appropriate – and be provided by trained counsellors. Since treatment is a long term commitment, counsellors will state the full picture of treatment, honestly and supportively.

A model way of knowing one’s status is to approach vulnerable groups in a cross-cutting approach. In Lebanon, the national AIDS programme and NGOs worked with education authorities to raise awareness inside schools and universities. The aim was to increase the opportunity to know one’s status, teach protective measures and tackle stigma. [4]

Treatment education

Treatment education is an essential component of the overarching term ‘treatment preparedness’ that sprung out of the 2002 International AIDS conference in Barcelona.  Treatment education should be directed at people living with HIV but also health care providers, educators, advocates, government officials, families and the wider community. An improved understanding of how ART works and targeting appropriate communities will promote better access to treatment. [5]

Education should address stigma and taboos of HIV in order for people to seek treatment from VCTs. Treatment education should extend to health care providers. According to a study in Egypt, mistreatment by health care providers at the Fever Hospital was degrading and upsetting to the women who were treated there.  Fear of being mistreated caused a number to seek health care privately and consequently without telling their doctors their HIV positive status.[6]

Strengthening existent medical and support services

Navigating health systems in the region can be a confusing, daunting and frustrating experience for people living with HIV. Health systems are often under-resourced and pose a lot challenges for treating HIV. An effective system must be able to provide treatment employing the most minimum bureaucracy, offering adequate and effective referral systems between the VCT and other treatment and support services, and navigation explained in simple messages – written or verbal.

Facilitating access to treatment depends upon health care providers being adequately trained on the rights of people in treatment and dispelling stigmas and mistruths about the disease. They should also advocate the importance of treatment. Health care providers should be informed and updated on new technologies in treatment so that they are equipped to relate to people living with HIV.

Access is also challenged in health care settings in negotiating the cost of ART and treatment of opportunistic infections. Cost has to be measured against long term financial sustainability.

Equity of Access

Expanding access to groups already socially, economically and culturally disadvantaged is a more equitable approach to providing treatment, rather than relying on purely clinical indicators. This means understanding the populations in the region that are most deserving and setting targets of treatment eligibility in proportion to local epidemiology. [7]

Antiretroviral therapies

About ART

Antiretroviral drugs disrupt the action of the HIV virus. Since the retrovirus mutates quickly, people with HIV are given a combination of ARVs.  ARVs have been proven to reverse the effect of the auto immune deficiency that in disease form is knows as AIDS, and delay its onset. They have also effectively restored the immune system reducing occurrence of opportunistic infections.[8]

ARTs are a long term life commitment and missing doses can led to serious health consequences. ARTs are now manufactured in fixed dose combinations: i.e. they can be taken in one tablet; but this can depend on the treatment regimens.[9] Sometimes treatment can fail due to drug toxicity, drug intolerance and non-compliance to the regimens (hence the importance of treatment education). Sometimes failure can indicate drug resistance. Treatment failure will prompt a change to second-line therapies and further counselling.

Pregnant women and ART

Pregnant women with HIV who are eligible for treatment must be given it. Stringent monitoring is required to assess the viral load levels and CD4+ count throughout the pregnancy. Administration of ART will not only improve the expectant mother’s health but can prevent mother-to-child-transmission.[10]

When to initiate ART

The goal of treatment is geared towards management of chronic infection therefore the maximum suppression of the HIV replication. Deciding when to initiate treatment depends on many factors but primarily health care providers and people living with HIV should discuss the pros and cons of starting treatment and make individualised informed decisions. Defining when treatment should start is controversial, but in principle there should be some damage to the immune system and HIV viral load is high and CD4+ cell loss has occurred. [11] It is recommended that national criteria for treatment initiation are developed by the countries themselves.[12]

Monitoring and Evaluating ART

Clinical monitoring of HIV treatment is done by measuring the plasma viral load and the CD4+ cell count. High quality laboratory monitoring is not widely available in low and middle income countries and therefore due to cost and expertise is sometimes approached in collaboration with treatment centres accredited to UNAIDS. Testing the viral load while on treatment is expensive. In the case of those who pay for treatment privately, unfortunately this is often sidelined in order to pay for more drugs.  Regular immunological and virologic monitoring can form the basis for research and treatment protocols.[13]

There is little data in the region on the level of extensive drug resistance (resistance to second-line drugs) but there are indications in the Islamic Republic of Iran.[14] This requires collaboration with international labs for expertise.

Cost of ART

As part of treatment education, the financial and social implications for receiving treatment are discussed at initiation of treatment. Sustainable finance systems should be implemented to ensure the poor are exempt from user fees as well as the drugs themselves. 3 by 5 Initiative Hidden costs have been shown to effect adherence to drug regimens.[15]

ART is available free on a limited basis in most MENA countries. In 2005 only 5% received treatment and only some countries managed to negotiate lower ART prices.[16] The Accelerated Access to Care Initiative supported by UNAIDS/WHO is negotiating with pharmaceutical firms in some countries of the region.[17]

In conjunction with counselling

Treatment should be given with voluntary counselling. Through this people will be told about what to expect and help them deal with the psychological and physical affects of their treatment.

Information on drug regimens

Commitment to treatment is fundamental and cannot be obtained without due knowledge on treatment requirements. People need information on how the drugs should be taken, the dangers of skipping doses, possible side effects, interaction with other medications and use of alternative treatments in case of toxicity or treatment failure. Provision of such information should be in a de-medicalised fashion with culturally appropriate messages. [18] This means using approaches that speak to the layperson in his or her language. This can be by way of booklets, fact sheets and posters. A successful method used is the “patient passport” or treatment diaries. This enables the person to keep track of his treatment regimens, appointments, test results, nutritional requirements, side effects experienced, etc. [19]

Nutrition and complementary therapies

Why good nutrition?

Good nutrition is part of every comprehensive treatment strategy. It helps to maintain the immune system especially since people with HIV tend to have poor nutritional status. Nutritional problems are related to symptoms like diarrhoea, loss of appetite, anaemia, mouth ulcers, and others which all affect the type of food they eat and their ability to digest food. Correct treatment and nutrition education will also dispel the misunderstanding that good nutrition is an alternative to ART.

Nutrition appropriateness in the region

Not all populations have complete access to good nutrition. Poor education might affect their knowledge of good nutritional food sources. Poverty will impede their access to good nutrition. The polarity in nutritional status in the region is vast with variances between the Gulf States to poorer countries like Yemen, Somalia and Sudan, as well as rural and urban disparities in food supply, and this is not to mention countries in conflict.

Nutritional requirements

People living with HIV need to be provided with the best nutritional advice according to the environment they live in.  Education must be given on sources of nutrients, best ways of cooking food for nutritional and hygiene benefits and price considerations. This information should be related to family and carers who may take nutritional needs as their responsibility.

People living with HIV need

Macronutrients:

Carbohydrates and fats: an adult with HIV needs 10-15% more energy.

Proteins: an adult with HIV needs 50-100% more than an uninfected adult

Micronutrients:

Vitamins A, B6, B12, iron, selenium and zinc to fight infections

Vitamin B6 supplements for people treated for TB

Children and pregnant women with HIV will need specialised nutritional advice.[20]

Complementary therapies

Complementary therapies are also employed as part of comprehensive treatment. Traditional healers popular in the region must be trained on treatment for HIV and understand that their therapies are just one part of comprehensive treatment and care, and not cures in themselves. Traditional healers have a large audience and provided that their treatment does not contradict with HIV treatment regimens can be instrumental in referring HIV cases to VCT, counselling and promoting prevention measures.[21]

Complementary therapies are becoming more popular in the region either through the resurgence of traditional indigenous therapies or more recently adopted ones. More information and research is required on what is available in the region and which therapies are of benefit to people living with HIV.

Opportunistic Infections

Due to the progressive deterioration in immune system, people living with HIV are more susceptible to opportunistic infections. Some are debilitating and life threatening, like TB, malaria, and Hepatitis B and C (HVB and HVC). Sexually transmitted diseases are also common opportunistic infections. Accurate monitoring of opportunistic infections of people living with HIV is important and sometimes prophylactic treatment of infections can be used.

In 2006, a report from nine countries in MENA showed that there was an average of 0.7% of people with TB being HIV-positive.[22] Sudan and Somalia have a higher incidence of TB and therefore TB programmes play a greater role in opportunistic infections. [23] Morocco has set up a sentinel sero-surveillance system which monitors HIV prevalence of people with TB. [24]

Integrating HIV treatment with other disease programmes

Synergising disease programmes to exploit best treatment options are recommended. Efforts can be directed from VCT in promoting anti-malaria actions in HIV programmes, treatment strategies for TB in workplace settings, include TB screening and treatment, and test for HVC and HVB and STDs. Similarly, HIV treatment can be managed through malaria and TB programmes. Health care providers in all such fields must be trained on the challenge of identifying and treating people with more than one life threatening infection.

 

[1] http://www.emro.who.int/asd/AboutASD-3by5.htm

[2] Draft Middle East and North Africa Briefing Note p1

[3] WHO EMRO , Regional Committee for the Eastern Mediterranean, 54th agenda, agenda item 4a Progress report on HIV/AIDS2p2

[4] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006page 12

[5] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006

[6] Hind Khattab,  Challenges involved in HIV/AIDS Research in the Political, Social and Cultural Context of the Arab, Global Forum for Health Research Forum 10, October 2006

[7] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006 P13

[8] Safe and Effective use of Antiretrovirals in adults, WHO/HIS/2000.04 P5

[9]Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006 IATT p15

[10] Improving access to care in developing countries: lessons from practice, research, resources and partnerships, report from meeting 2001, UNAIDS p47,

[11] Safe and Effective use of Antiretrovirals in adults, WHO/HIS/2000.04 P 6

[12] Safe and Effective use of Antiretrovirals in adults, WHO/HIS/2000.04 P21

[13] Safe and Effective use of Antiretrovirals in adults, WHO/HIS/2000.04 P14

[14] World Bank, 2002, responses to HIV/AIDs p2

[15] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006P18 IATT

[16] http://www.emro.who.int/asd/pdf/Strategy_HIV-AIDS_06-10.pdf

[17] World Bank, 2002, responses to HIV/AIDs p71

[18] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006 P 15

[19]Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006 p16

[20] Improving access to care in developing countries: lessons from practice, research, resources and partnerships, report from meeting 2001

[21] Inter-Agency Task Team (IATT) Treatment Education, UNAIDS, June 2006 p31

[22] WHO EMRO , Regional Committee for the Eastern Mediterranean, 54th agenda, agenda item 4a Progress report on HIV/AIDS2p2

[23] Dr Laura GIllini, EMR/WHO TB/HIV State of the Art and way forward

[24]

Last Updated ( Friday, 30 October 2009 09:17 )  
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