Universal access

In order to highlight the need for sustainable and affordable access to quality medicines, the Executive Director of UNAIDS, Michel Sidibé, spoke about the necessity of implementing the African Union Pharmaceutical Manufacturing Plan. Speaking at the opening ceremony of Africa Industrialization Week 2018 in Addis Ababa, Ethiopia, he called for close cooperation with regional economic communities in order to build production cooperation hubs and lead pharmaceutical regulatory harmonization in Africa.

Commitments on gender-based violence and the rights of women made at an event held on the margins of the United Nations General Assembly in September entitled Eliminating Sexual and Gender-Based Violence and Protecting the Health and Rights of Women and Children in Humanitarian Settings were discussed during meetings Mr Sidibé held with Smail Chergui, the Africa Union Commissioner for Peace and Security, and the African Union Special Envoy on Women, Peace and Security, Bineta Diop.

During the meetings, discussions were held on how to increase efforts in responding to HIV in conflict and humanitarian settings and the need to increase awareness on HIV testing and on sexual and gender-based violence. Mr Sidibé and Mr Chergui agreed to conduct a high-level joint mission to South Sudan to highlight the needs of people facing a higher risk of HIV in the country owing to gender-based violence and the protracted conflict.

Also during his visit to Ethiopia, which took place from 17 to 20 November, Mr Sidibe’s met with Ethiopia’s Prime Minister, Abiy Ahmed, who said, “I am committed to change the narrative of Africa and Ethiopia through ongoing reforms and agree to strengthen efforts on people-centred health development for Ethiopia.”

“Thank you for agreeing to champion ending AIDS in Ethiopia and across the continent,” said Mr Sidibé.

The President of Ethiopia’s agenda on gender and peace and the rehabilitation of street children was the topic of conversation in a meeting between the President, Sahle-Work Zewde, and Mr Sidibé.

During a discussion Mr Sidibé had with the Minister of Health of Ethiopia, Amir Aman, a collaborative project was developed that will be centred around strengthening resource mobilization, enhancing and sustaining a multisectoral response across all sectors, engaging young people and enhancing HIV programmes following the location–population approach.

The Russian Minister of Health, Veronika Skvortsova, has reiterated the commitment to reach the targets agreed at the 2016 United Nations General Assembly High-Level Meeting on Ending AIDS.

“We have to provide every person living with HIV with quick access to the correct treatment. The Ministry of Health plans to increase the coverage of people living with HIV who know their status on antiretroviral therapy to 75% by 2019, and by 2020 the figure should reach 90%,” said Ms Skvortsova at the 28th meeting of the Health Council of the Commonwealth of Independent States, held in Saransk, Russian Federation, on 4 September 2018.

In 2018, the Russian Federation reported for the first time on national progress towards the 90–90–90 targets—in 2017, 81% of people living with HIV in the Russian Federation knew their status, 45% who knew their status were on treatment and 75% who were on treatment were virally suppressed.

In order to improve strategic information and build evidence for decision-making at the local level, the Russian Ministry of Health recently conducted a workshop on HIV estimates for representatives of 10 Russian regions. Regional experts were trained on modelling HIV estimates, which will help to ensure a more complete picture of the number of people living with HIV and of the 90–90–90 targets at the subnational level.

Eastern Europe and central Asia is the only region in which the numbers of new HIV infections and AIDS-related death are still on the rise. At the end of 2017, the number of new HIV infections in the region reached 130 000. At the end of 2017, it was estimated that the 90–90–90 cascade in the region was 73%, 50% and 72%.

“The Russian Minister of Health’s statement is another important step in a series of consistent actions undertaken by the Government of the Russian Federation to accelerate the country’s Fast-Track approach to reach 90–90–90 by 2020,” said Vinay P. Saldanha, Director of the Regional Support Team for Eastern Europe and Central Asia.

African ministers of health, the Chinese Minister of Health and others have examined ways in which China can be instrumental in building capacity for the local production of health commodities in Africa and in strengthening regulatory capacities. The participants met at the 2018 High-Level Meeting on China–Africa Health Cooperation, held on 16 and 17 August in Beijing, China.

Africa is hugely dependent on imported medicines and other health technologies. It is estimated that 70% of the pharmaceutical and medical products market is served by imports. Demand for health commodities is growing rapidly and cannot be met with Africa’s existing manufacturing capacity and sources of supply.

During the event, the Chinese participants learned about African best practices, including the progress made in expanding HIV treatment, responding to the HIV epidemic in rural areas and reducing new HIV infections among children.

“We are creating the enabling environments for investments in Nigeria and closing the gap in supply shortages for essential commodities. Now is the time to stimulate access and increase local production of essential medicines and health technologies in line with our goal of achieving universal health coverage,” said Isaac Adewole, the Nigerian Minister of Health.

The participants signed a six-point document, the China–Africa health cooperation 2018 Beijing initiative, which focuses on building a strong public health surveillance and response system in Africa and supporting the response to public health emergencies. The plan also includes a special focus on strengthening cooperation on HIV prevention, in particularly among young people and key populations.

Antiretroviral stock-outs are a serious public health problem in the Latin America region and represent an important risk to the sustainability of the HIV response, according to participants at AIDS2018.

On July 26, a session titled Sustainability of the response to HIV in Latin America; factors that impact access to drugs and health supplies addressed and analyzed the magnitude, the structural causes and the impact of stock-outs on the sustainability of the HIV response in Latin America. Participants discussed strategies to pave the way forward and highlighted best practices on joint purchases of antiretroviral (ARV) treatment like the PAHO/OMS strategic fund, which has helped prevent stock-outs.

In Latin America, one of the most important achievements in the HIV response has been the recognition that accessing HIV treatment is part of the right to health in the public health system, resulting in an increased number of people receiving antiretroviral treatment in recent years. However, a major challenge to fulfill the right to health is to guarantee uninterrupted supplies of ARV drugs and other essential health commodities.

According to the Pan American Health Organization (PAHO), in 2012 45% of the countries reported at least one stock-out episode; the figure had been 54% in 2010. Although some improvements are seen from 2010 to 2012, the region is still experiencing a high frequency of stock-outs.

Shortages of ARVs and other essential supplies result in changes and interruptions in patient treatment, threaten the lives of people with HIV and hamper the reduction of new HIV infections and AIDS-related deaths.

Participants at the session stressed the need for greater health system strengthening and joint procurement processes, including the incorporation of TRIPS flexibilities to reduce ARV costs, aligned with policies for simplified treatment regimens. According to participants, all these factors are essential to prevent and respond to stock-outs of ARVs and medical supplies.

At the United Nations High-Level Meeting on Ending AIDS in 2016, countries pledged to achieve a set of 10 Fast-Track commitments by 2020—an acceleration agenda that aims to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals. To help ensure that the deadlines are met, the United Nations General Assembly requested an annual report on progress achieved in meeting those 10 commitments.

UNAIDS supports countries to collect information on their national HIV responses through the Global AIDS Monitoring (GAM) framework—an annual collection of 72 indicators on the response to HIV in a country. These data form part of the data set used to report back to the General Assembly.

Different from the HIV epidemiological estimates that countries produce for data on the state of the epidemic in a country—that is, data for making estimates on the number of people living with HIV, AIDS-related deaths, etc.—GAM collects information on HIV programmes, including the number of people living with HIV who know their HIV status and people on HIV treatment, and on stigma and discrimination. A full list of the indicators is given in the GAM guidelines.

A remarkable feature of the data collection for GAM and the HIV epidemiological estimates is the speed with which the information is collected, submitted and disseminated. UNAIDS distributes the GAM guidelines to countries each December. Countries submit their data online by the end of March. In collaboration with the World Health Organization, the United Nations Children’s Fund and the European Centre for Disease Prevention and Control, the data are validated and finalized. The HIV epidemiological estimates are produced along the same timeline, with the software made available to countries in early January and the final estimates submitted by countries at the end of March. The analysis of the global results of both data collections are published in UNAIDS’ mid-year report and on the AIDSinfo website, and ultimately are reported to the United Nations General Assembly.

Despite the short reporting timeline, in 2017 a total of 174 countries submitted data on their programmatic response indicators through GAM. The proportion of countries submitting data through the GAM website has steadily improved, from 53% of countries reporting in 2004 to 96% reporting in 2012, although reporting dropped to 90% in 2017, when the reporting cycle changed from biennial to annual. Before 2015, GAM was known as the Global AIDS Response Progress Reporting (GARPR) and was used to report on global targets for the AIDS response under the Millennium Development Goals.

A key component of ensuring that HIV-related data are as accurate as possible is collecting the right information to begin with. Therefore, each year a review of each indicator is made and adjustments to the set of indicators are made in order to ensure that the information on the national AIDS responses is accurate and relevant. In 2018, two new indicators—on HIV testing among pregnant women and on experiences of HIV-related discrimination in health-care settings—were added, while others were modified.

The indicators are carefully selected in order to ensure the maximum data collection with the least burden on the countries’ monitoring systems and are aligned with the indicators for the Sustainable Development Goals. The indicators are also granular, with countries requested to provide data disaggregated to the city level for some indicators.

Looking to the future, community-led data collection, such as through mobile applications or community observatories, are being looked into as complementary data collection tools for different insights into countries’ AIDS responses.

GAM is yet another way that UNAIDS is helping countries to monitor and respond to their HIV epidemics and work towards ending AIDS by 2030.

People living with HIV and other chronic illnesses are getting faster, simpler access to essential medicines thanks to new medicine dispensing machines being piloted in Johannesburg, South Africa.

The non-profit organization Right to Care is testing three pharmacy dispensing units at a shopping mall and two hospitals. Most of the people using the new machines are accessing repeat prescriptions for HIV medicines.

The machines connect users to pharmacy assistants by video for remote consultations in any of the 11 official languages of South Africa. The entire process, from consultation to the release of the medicines from the machine, takes only a few minutes.  

The machines are integrated with public health facilities responsible for patients with chronic conditions, in order to ensure that patients receive and adhere to effective treatments. The users of the machines get a printed receipt with the date of their next visit and receive a reminder by SMS. The system alerts pharmacists if patients are late to collect their medicines.

The device could be a game-changer for expanding access to HIV treatment. The South Africa UNAIDS Country Director, Mbulawa Mugabe, said, “One of our biggest challenges today in most countries in Africa is that health facilities are packed. We need to find ways in which we can relieve the congestion in the interest of patients themselves and also for the health systems.”

People living with HIV can often wait several hours to have their prescription filled at a local clinic. The process also takes up valuable time for skilled pharmacists. Now those tasks are being handled by junior pharmacists, who work with a robotic system to dispense pills in a matter of minutes.

The pharmacy dispensing units were engineered by Right to Care’s subsidiary Right e-Pharmacy in collaboration with the German company Mach4 and supported by German and American development agencies GIZ and USAID. The current trials are being conducted in collaboration with the Gauteng Department of Health and Right to Care hopes to expand the trial to two other African countries in the near future.

South Africa has the highest rate of HIV prevalence in the world and provides free treatment to 4.2 million people. The President of South Africa, Cyril Ramaphosa, recently set a target of expanding HIV treatment to an additional 2 million people by 2020. With millions of South Africans accessing medicines from clinics and hospitals, innovations such as these dispensing machines promise to help South Africa achieve its ambitious targets.

South Africa tests potential game-changer in HIV treatment

Zaheer Cassim reports for VOA from Alexandra township in Johannesburg.

Ending the AIDS epidemic among children, adolescents and young women requires ambitious targets and a Super-Fast-Track approach. Building on the successes of the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, UNAIDS, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and partners* launched Start Free Stay Free AIDS Free in 2016 to provide a framework for the urgent work ahead.

Start Free Stay Free AIDS Free prioritizes action in 23 countries** that account for 87% of new HIV infections among children aged 0–14 years and approximately 87% of all children and adolescents living with HIV globally. In 2016, 2.1 million children were estimated to be living with HIV.

In its first progress report, Start Free Stay Free AIDS Free reflects on the achievements made during the first year of implementation and highlights areas where urgent action is needed.

“The world is on the Fast-Track to eliminating new HIV infections among children and ensuring that their mothers are alive and healthy, but we need to do more to ensure that all children living with HIV have access to treatment immediately,” said Michel Sidibé, Executive Director of UNAIDS.

The report shows that globally in 2016, there were 160 000 new HIV infections among children and that 140 000 occurred in the 23 priority countries. Although there was an overall decline in new HIV infections, the decline was at a much slower rate than in previous years.

The report highlights concerns around new HIV infections among young women and girls. In 2016, around 200 000 adolescents between the ages of 15 and 19 years were newly infected with HIV in the 23 priority countries, 72% of whom were young women.

Most—more than 70%—of all new HIV infections among young people are in sub-Saharan Africa, which also has the fastest growing youth population in the world.

“A high number of new HIV infections among adolescents and a fast-growing population could make for an HIV explosion among young women in Africa,” said Deborah Birx, United States Global AIDS Coordinator and Special Representative for Global Health Diplomacy. “The United States Presidents Emergency Plan for AIDS Relief is driving harder and smarter to prevent HIV infections and ultimately help end AIDS among children, adolescents and young women. Every person deserves the chance to survive, thrive and pursue their dreams.”

Gains seen in access to treatment

The report shows that while important gains have been made in access to antiretroviral therapy for pregnant women living with HIV, much more needs to be done to reach children.

In 2016, around 78% of pregnant women living with HIV had access to antiretroviral therapy in the 23 priority countries.

Start Free targets

Reduce new HIV infections among children to 40 000 by 2018.

Reach and sustain 95% of pregnant women living with HIV with lifelong HIV treatment by 2018.

Stay Free targets

Reduce the number of new HIV infections among adolescents and young women to less than 100 000 by 2020.

Provide voluntary medical male circumcision for HIV prevention to 25 million additional men by 2020 globally, with a focus on young men aged 10–29 years.

AIDS Free targets

Ensure that 1.6 million children (0–14 years) and 1.2 million adolescents (15–19 years) living with HIV have access to antiretroviral therapy by 2018.

The increase in the roll-out and uptake of antiretroviral therapy during pregnancy and throughout breastfeeding is estimated to have averted around 270 000 new HIV infections among children in 2016 alone.

The numbers of children on treatment has also increased, but not on a big enough scale. In 2010, only 17% of children aged 0–14 years had access to treatment. By 2016, that had risen to around 43%, with around 920 000 children accessing antiretroviral therapy. Although this is a marked improvement, access to treatment for children still falls far behind access for adults. In 2016, around 54% of adults living with HIV had access to treatment.

The report cites multiple reasons for the slow growth of access to treatment for children, including poor testing rates. Only nine of the 23 priority countries managed to test and diagnose 50% or more of children who were exposed to HIV in 2016. There are particularly low rates of early infant diagnosis in the first two months of life, when it is most important to test, as HIV-related mortality is at its highest. Without access to testing and treatment, half of all children living with HIV will die before their second birthday.

Ways forward

The report offers a set of important actions countries can take to eliminate new HIV infections among children, to test and diagnose children and young people who may have been exposed to HIV and to ensure that children and young people access HIV prevention, quality medicines and age-appropriate sexual and reproductive education and care and support throughout their lives, free from stigma and discrimination.

Other important actions include accelerating new medicines and diagnostics, promoting community engagement and services, voluntary medical male circumcision, access to information on sexual and reproductive health and access to pre-exposure prophylaxis for young people at a higher risk of HIV.

“The future for children and adolescents depends on actions we take collectively today,” said Mr Sidibé.

The latest estimates, for the end of 2017, will be released in July 2018 and will provide further insight into the progress of Start Free Stay Free AIDS Free.

* United Nations Children’s Fund, World Health Organization and the Elizabeth Glaser Pediatric AIDS Foundation.

**Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Uganda, United Republic of Tanzania, Swaziland, Zambia and Zimbabwe.

Shiv Kumar, from Swasti Health Catalyst in India, decided to build a mobile and web application called Taaras (rapid progress). He had watched peer educators work with sex workers in Bangalore, India, and realized that he could make their jobs a lot simpler and more efficient. The south-east Indian city has become a major hub and, as a result, the population has boomed, as have sex workers. 

After seeing outreach workers, mostly former sex workers, lugging notebooks and jotting down information and recalling appointments and treatment pickups, he created an app that helps with data collection. “Icons and swipes allow outreach workers to enter all sorts of stuff and swipe and pick up where they left off,” Mr Kumar said. They can also text multiple recipients with reminders and invitations.

“Outreach can no longer be a one-way street. You have to engage the patient,” he said.

The app rolled out in five Indian states in English as well as four regional languages. Since its debut in March 2016, there are now more than 400 users following about 120 000 sex workers.

Bangalore outreach worker Natranity said that she has a lot less paperwork to deal with. “All the data of a particular person is now in one place, versus five or six registers that I had to consult,” she said. Her colleague, Abdul, agreed, “I see about 10 to 15 people a day and what saves me a lot of time is not asking the same questions over and over again, because I can consult their profile.”

The phones had their limits, they explained. “At the initial stage, it’s important to build trust to avoid any discomfort in case they think we are taking photos or recording them,” Natranity said. 

Prachi Patel, a technology developer at Swasti, sees Taaras as a bridge to an overall solution. “The app is a helper; outreach workers still do all the talking,” she said. A by-product of the app has been higher engagement with sex workers and an increase in reporting incidents of violence. For confidentiality, the app has a stress password that scrambles the data in the event that someone tries to access the information. 

UNAIDS Senior Adviser Philippe Lepère commends such efforts and believes e-health has a huge potential. Not only can it strengthen health systems, it also empowers people to manage their own care. Referring to the World Health Organization’s Guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach, he said that they advocate using text messages to remind people to take their treatment and encourage newly diagnosed people to seek out services.   

For this to work, however, he stressed the importance of confidentiality and respect of the user. “Receiving an HIV-related SMS can have drastic consequences in some communities,” he explained. That's why, he said, the content and the frequency have to be ironed out beforehand. “Most importantly, it’s urgent to shift from pilot studies to a larger implementation of programmes at a sufficient scale that can then be integrated within health systems,” Mr Lepère said. 

“In certain countries, digital apps have flooded the market and the government has no way of accessing the data or doing any quality control,” he said. 

Hani Eskandar, from the International Telecommunications Union, definitely sees mobile phones as paving the way towards universal health coverage.

But, in his view, e-health systems are far from a reality. “Countries have not yet grasped the benefits of this, because they are still focused on vaccines and building hospitals rather than outreach,” he said. He is pushing for governments to rebuild infrastructures that integrate digital platforms.

“It's simple,” he said. “We need for mentalities to change at all levels and stop thinking that the phone is just a gadget.”