Achieving an end to the AIDS epidemic:Laying the groundwork

published on April 7, 2015 by Editor, in The Guardian

Community campaigns, including those that provide screening or prevention services for multiple diseases, have proven effective in Nigeria, Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zambia. Further efforts are required to normalize HIV testing in health care settings.

Recent efforts by Nigeria to provide HIV testing as the entry point for the minimum package of prevention interventions (MMPI) is encouraging and will rapidly increase the uptake of HIV counseling and testing.

Pilot projects in both concentrated and generalized epidemic settings suggest that home-based testing is highly acceptable, in part because it protects confidentiality, as a complement to, rather than a replacement for, provider-initiated or facility-based HIV testing and counselling services.

Substantially increasing the demand for HIV testing is essential. This requires robust and sustained investment in community-based HIV literacy programmes. Enhanced support for strengthening community systems is also needed, to broaden awareness of the availability of simple, easily tolerated regimens, increase access to user-friendly testing options and alleviate stigmatizing attitudes that deter many from seeking testing services.

Focused, community-centred testing outreach can help reach marginalized populations at elevated risk of HIV infection. FOURTH-GENERATION HIV TEST This new test adds p24 antigen to the HIV antibody test to permit detection of the disease before seroconversion. This new test can detect the presence of HIV in the first week of infection.

Rapid tests, ELISA and Western blot (WB) detect positive samples only at seroconversion which occurs after 3 months of HIV infection.

This test is approved by the US Food and Drug Administration (FDA), and its use is recommended by the Centers for Disease Control and Prevention (CDC) and will hopefully become available in low and middle income countries in the near future.

The test will be a very useful test for screening patients because it can detect HIV during the early acute retroviral syndrome stage unlike the WB results, which require waiting for 2-3 months after viral transmission. Advantages of this early detection include (1) the possibility of functional cure (discussed below); (2) treatment at the time of maximum risk for transmission; and (3) the opportunity for direct entry into HIV care vs. the long delay required for obtaining a positive WB result.

This delay leads to 20%-25% of patients with a positive WB never actually receiving their results. Consequently, their care may be delayed or they may be lost to care. POINT-OF-CARE CD4 COUNT AND HIV VIRAL LOAD TESTING Point-of-care (POC) HIV testing has been extremely successful as a screening tool to detect HIV.

Now, there is a POC CD4 count test that permits staging HIV at the site of care and it is anticipated that a POC viral load test will also be available, although the timeline for this development is unclear.

The advent of the POC CD4 and viral load tests permits patients to test their own viral load to facilitate HIV management in an outpatient setting, often without the need for frequent medical evaluation except to test for drug toxicity, Co-morbidities, and HIV-related complications.

The long-term goal would be self-care akin to standard diabetes management. PREVENTING VERTICAL TRANSMISSION Several studies have shown that when pregnant HIV positive women have access to antiretroviral drug combinations, the risk of transmitting the virus to their babies is less that 5%.

As a result of this scientific information, access to Prevention of Mother to Child Transmission (PMTCT) of HIV services has increased dramatically. By 2012, 62% of pregnant women worldwide living with HIV had access to antiretroviral drug combinations and in several countries coverage levels are well above 80%. However, Nigeria has made very slow progress (30% coverage) despite efforts at scaling up PMTCT due to a number of structural challenges including inadequate services at the level of PHC, poor attendance of pregnant women of antenatal care services; many women preferring to go to Traditional Birth Attendants (TBAs), churches and mosques to access antenatal care and delivery services.

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Achieving an end to the AIDS epidemic:Laying the groundwork

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