Countries such as China, Cambodia and Vietnam have made
strong commitments to curbing their HIV epidemics through the expansion of HIV
testing and antiretroviral treatment, but numerous challenges remain, according
to speakers at 7th International AIDS Society
Conference on HIV Pathogenesis, Treatment and Prevention in Kuala Lumpur this week.
The uptake of counselling and testing is low in many key
populations, stigma remains a very real issue, a substantial number of people
are not linked to care or become lost to follow-up, adherence is sub-optimal
and most countries are reliant on international donors to sustain their
programmes, the conference heard.
With just under five million people living with HIV, the
Asian region has the second highest HIV burden in the world, after sub-Saharan
Africa. No country in the region has a generalised epidemic – the
greatest burden is among injecting drug users, men who have sex with men, sex
workers and their clients.
But significant progress has been made
in several south and south-east Asian countries. In Cambodia, India, Malaysia,
Burma, Nepal and Thailand, the rate of new HIV infections fell by more than 25%
between 2001 and 2011.
And while political leadership is
lacking in some countries, others have announced ambitious plans, galvanised by
the HPTN 052 trial of treatment as prevention.
Cambodia has already brought
antiretroviral treatment to 87% of those eligible
In a plenary, Dr Mean Chhi Vun of the
Cambodian Ministry of Health announced ‘Cambodia 3.0’, a plan that aims to
eliminate new HIV infections in the country by 2020. Having already brought
antiretroviral treatment to 87% of those eligible for it (the highest rate in
the region) the focus will now be on rapid identification of new cases and
immediate therapy; peer-initiated prevention work and linkages to services for
most at-risk populations; and better integration of reproductive health,
tuberculosis and HIV services.
five-year plan (published in February 2012) set a target for more than 80% of eligible people receiving antiretroviral therapy.
Current guidelines recommend that people who are in a serodiscordant relationship
should take therapy, whatever their CD4 count, as long as they wish to and can
adhere. China will now need to decide if it will implement the World Health
Organization’s new guidance, recommending HIV treatment at CD4 counts below 500
cells/mm3, rather than 350 cells/mm3.
China’s plan also includes goals on scaling up HIV testing,
especially for pregnant women, and condom distribution. It aims to increase interventions for sex
workers, people using drugs and men who have sex with men, without fully
addressing the human rights issues for these populations.
is currently completing a pilot of WHO and UNAIDS’ Treatment 2.0 programme in
two provinces, which incorporates simplified diagnostic tools, a low-cost
community-led approach to delivery and community mobilisation in order to
facilitate scale-up. In Vietnam there has been a particular focus on improving the
care cascade for key populations, including integrating provision of methadone
maintenance therapy, HIV testing and HIV treatment as a ‘one-stop’ service.
speed at which access to treatment has already been expanded in these countries
is highly impressive. In the year 2000, nobody was taking therapy in Cambodia
and now almost 50,000 people are (87% of those eligible). During the same time, China
– where the population is one hundred times greater but HIV prevalence
considerably lower – treatment coverage has gone from zero to over 80% of
adults with a CD4 count below 350 cells/mm3, Dr Fujie Zhang
of the National Center for AIDS/STD Prevention and Control (NCAIDS) told the
But coverage is highly variable, depending on risk
groups, he said. In 2009, four in five of those infected through blood
transfusions were receiving ART, compared to three in five of those infected
through sex and two in five injecting drug users.
Moreover, the newer treatment guidelines for people in
serodiscordant couples with more than 350 CD4 cells/mm3 are still to
be fully implemented. In 2012, one in five was receiving treatment.
But the approach is beginning to pay off, he
suggested. Whereas data from an eight-year period released last year showed that HIV transmissions were
reduced by 26%, he presented new data from the year 2011 alone, suggesting a
52% reduction. Just over 30,000 couples were followed – amongst those not on
treatment, the incidence rate was 2.1% a year (two in one hundred acquired HIV
each year), compared to 1.0% when the positive partner was taking treatment.
But these rates remain poorer than that seen in the
HPTN 052 clinical trial, most likely because adherence was not as good as it
Lo of the World Health Organization’s regional office
underlined the importance of plugging gaps in the treatment cascade. In
Vietnam, she said, there are estimated to be around 250,000 people living with
HIV, of whom 200,000 know their status. The biggest gap comes next – just
72,000 people are linked to care, of whom 61,000 are on therapy.
In China, while 780,000 are living with HIV, fewer than
half (352,000) have been diagnosed. Moreover only a minority (126,000) of the
diagnosed are now on therapy, with 64,000 having their viral load monitored and
confirmed to be suppressed.
Dr Ying-Ru’s figures were not the same as Dr Fujie’s,
underlining the point she made about uncertainties in the data and the
importance of developing more robust public health surveillance systems to
accurately measure the problem.
Mean of Cambodia outlined some of the steps that have been taken over the past
decade to tighten up the country’s treatment cascade. Voluntary HIV testing,
initiated by healthcare providers, is now available at a quarter of the
country’s 1049 community health centres (which provide antenatal and
tuberculosis services, amongst other things), rather than just referral
hospitals. Moreover health centres without testing facilities have been linked
to centres that could offer the service, which has been key in expanding
ambition in Cambodia 3.0 is for all health centres to offer point-of-care HIV
testing (rather than taking blood samples for laboratory testing), which will
substantially streamline the number of steps required to make a diagnosis and
link to care. Furthermore, there will be a greater integration of antenatal, TB
and HIV services.
Dr Ying-Ru Lo underlined the importance of plugging gaps in the treatment cascade
Duc Duong of the Viet Nam Authority of HIV/AIDS Control said that point-of-care
CD4 testing could cut out what had previously been a three-to-four month wait for
CD4 results and, if necessary, commencement of treatment. But he also pointed
out that, at present, 51% of people start treatment at a CD4 cell count below 100
cells/mm3, underlining the urgency of expanding
access to treatment, regardless of its prevention benefit.
Moreover, late diagnosis is especially common in key
populations. Forty per cent or less of injecting drug users, men who have sex
with men and female sex workers have been tested in the previous year, he told
there may be greater scope to scale up HIV testing and treatment in a
concentrated, rather than generalised epidemic, because the pool of people to identify and treat is concentrated and relatively small. A recent modelling study, based on a Vietnamese
province, found that reaching all people who inject drugs with testing and
treatment would cost only 7% more than current activities, but avert 75% of all
new HIV diagnoses.
Dr Mean said that expanding community based testing
for sex workers, injecting drug users and men who have sex with men was part of
Cambodia’s plans. Moreover, he expressed a commitment to working with civil
society and peer networks to work with these populations on linkages to health
services. “We do
not have GIPA but we have RIPA,” he said, referring to the ‘real’ involvement
of people living with AIDS and most at-risk populations. “They are involved not only in service
delivery, but also policy formulation, programme design, and monitoring and
evaluation,” he said.
acknowledged that stigma, discrimination and other structural barriers remained
considerable obstacles to improving the health of marginalised groups. For
example, laws designed to curtail human trafficking had led to a rapid and
disorganised closure of brothels and drove sex workers underground, making them
much harder to reach.
the region, people who use drugs are frequently detained in compulsory drug
‘treatment’ centres. Police activity frequently hinders the delivery of any
health services to this population.
structural barriers to sustainable delivery of treatment as prevention are the
strength of country’s health systems and finance. In Vietnam and Cambodia,
respectively 73 and 90% of funding comes from international donors, but there
is pressure for the domestic contribution to increase. China, however, largely
pays for its own response to HIV.
speakers identified a number of research questions to address:
- Identifying acceptable and effective approaches to promote
regular HIV testing and uptake of HIV treatment in key populations.
- Developing interventions and models of service delivery to improve the treatment cascade, especially in key populations.
- Understanding and developing the role of peers and
communities in facilitating these programmes.
- Developing interventions to reach the sexual partners of
people living with HIV.
- Developing interventions to reach individuals with very
recent HIV infection, who are likely to have a disproportionate impact on HIV
- Understanding the cost and cost-effectiveness of
- Developing public health surveillance and monitoring