Durban, South Africa—Global HIV/AIDS leaders at the International AIDS Conference in Durban must develop and implement an action plan to address the critical lack of access to HIV treatment in countries in West and Central Africa where coverage remains below 30 percent, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) Tuesday.
At a hospital where MSF works in Kinshasa, Democratic Republic of Congo, one quarter of people with HIV arrive too sick to be saved; 39 percent of these patients die within 24 hours of being admitted to the hospital, said MSF. In Central African Republic, 84 percent of deaths in Beberati Hospital where MSF works are related to HIV/AIDS, even though national HIV prevalence is believed to be below 5 percent. In the north of the country, in Ndele, Kabo, and Batangafo, MSF teams report HIV positive rates of 33 percent at the voluntary counseling and testing level.
"The HIV situation in west and central Africa reminds us of the terrible days over a decade ago in southern Africa, when people were dying and no treatment was available," said Dr. Eric Goemaere, HIV/TB unit coordinator for MSF's Southern Africa Medical Unit. "Solutions to close this massive treatment gap exist; we need a massive booster shot for west and central Africa if we’re going to get anywhere close to achieving the global treatment goals. When there are so many millions of people on treatment today, the right to access that lifesaving treatment should not depend on where people live. We cannot leave these people behind."
Failing to reach people in neglected regions risks global goals to put 30 million people on treatment by 2020. Also at risk is UNAIDS 90-90-90 targets for 2020, in which it aims to have 90 percent of people with HIV aware of their HIV status and 90 percent of those people on antiretroviral treatment. Under the 90-90-90 targets, 90 percent of people on antiretroviral treatment would have undetectable levels of virus in their blood, and viral suppression would be achieved by 2020.
In order to reach these goals, an additional 13 million people need to be reached with treatment, a third of whom live in west and central Africa. Adopting community-based strategies could help expand coverage in west and central Africa, where barely one in four people among the 6.5 million with HIV in the region have access to treatment. Nearly one third of AIDS-related deaths globally occur in the region.
New MSF data from southern Africa suggests that providing antiretroviral treatment at time of diagnosis is feasible but that community-led outreach is necessary to test and link people living with HIV to care and to ensure that they have support on lifelong antiretroviral treatment.
In MSF’s project in Swaziland, data from across nine health facilities in rural Nhlangano district showed that of people who started treatment earlier in the progression of their disease—with a CD4 cell count above 500—90 percent were still on treatment after six months. In MSF’s project in KwaZulu-Natal (KZN) province, South Africa, when offering treatment including to people with higher CD4 counts, over 80 percent of people remained on treatment after 12 months, whether they had started treatment below or above CD4 350. Initiation rates remained stable for people at CD4 levels below 350. These findings suggest that newly eligible patients will initiate and remain on antiretroviral treatment if provided the opportunity, without compromising access to care for the sickest people.
However, testing and offering people treatment and ensuring lifelong adherence will not be possible without outreach activities that target testing people before they are ill. Community testing strategies piloted by MSF in KZN are particularly effective at reaching first-time testers, including students, young women at risk of HIV, and young men who may not attend health facilities. Door-to-door testing by community health workers reaches people of all ages, and can even be less expensive than facility-based testing. Importantly, people diagnosed at mobile and stand-alone sites in 2015 had higher median CD4 counts (462 cells/mm³) compared to those diagnosed in facilities (CD4 363 cells/mm³).
While policies and practices for employing lay workers vary widely when they are absent from the health system, the impact is substantial. After lay counselors were withdrawn from facilities in KZN province in two waves during 2015, the monthly average number of HIV tests conducted in facilities MSF supports in Eshowe/Mbongolwane decreased by 25 percent and a further 13 percent respectively. The number of new people starting on treatment in the area also declined by 20 percent in 2015.
"Patient care works like dominoes, with an entire community involved in testing people where they live and work, and ensuring that someone who tests positive is initiated on treatment, and supported to stay adherent to lifelong treatment with suppressed levels of the virus," said Musa Ndlovu, deputy field coordinator for MSF in KwaZulu-Natal. "The lay workers in communities and facilities are the glue holding everything together—improving both quality of care and access. We need governments to ensure that a workforce of lay people is employed, maintained, and expanded throughout the region, to provide testing, treatment initiation, and adherence support for all who need it."
MSF has been providing antiretroviral treatment to people living with HIV/AIDS since 2000, and currently supports HIV treatment for nearly 240,100 people in 19 countries.