Challenges in expanding access to antiretroviral therapy for key affected populations.

Abstract

Evidence showing the individual and public health benefits of antiretroviral therapy (ART) has galvanised global efforts to increase the number of people receiving ART, particularly in low- and middle-income countries. Significant treatment gains have undoubtedly been made, particularly in sub-Saharan Africa, with recent reports showing that approximately 9.7 million people were receiving ART in 2012, approximately 65 per cent of the 15 million people targeted to access ART by end of 2015.1 Marked disparities in access to ART persist, however, with treatment gains not reaching enough children, adolescents and key affected populations (KAP), including sex workers, people who inject drugs (PWID), men who have sex with men and transgender people. Human immunodeficiency virus (HIV) testing represents the first step of an HIV treatment cascade that needs to be followed by receipt of test results, linkage and retention in care, initiation of HIV therapy and, ultimately, viral load suppression.2 The challenges in maintaining this cascade are particularly burdensome in low- and middle-income countries and in treatment programmes focusing on KAP. In this issue of Public Health Action, Denisiuk and colleagues describe the low rate of HIV testing in more than 190 000 people at high risk of HIV infection attending HIV prevention programmes implemented by local and international non-governmental organisations in Ukraine.3 Opportunities to increase the rate of HIV testing amongst those who initially test negative in these treatment programmes were also lost, with no more than three in 10 undergoing retesting within a year of the initial test. Different models of care, ranging from dedicated centres for KAP to integrating HIV testing into methadone treatment centres, have been implemented to improve HIV prevention and treatment amongst KAP.4,5 In a large study involving 13 methadone treatment centres in Yunnan Province, China, 33% of 1935 individuals attending the centres were diagnosed with HIV on enrolment. Biannual HIV testing amongst those who attended the programme diagnosed 13 new episodes of seroconversion amongst the participants. The rate of loss to follow-up in these treatment centres was unfortunately high, representing another lost opportunity to improve HIV testing and counselling.5 Suboptimal HIV testing has been reported across all risk groups. In addition to difficulties in gaining access to HIV testing centres, fear as a consequence of criminalisation of drug use, sex work and homosexuality represents barriers to HIV testing among KAP in several countries. Furthermore, stigma and discrimination, fear of knowing their HIV status and lack of knowledge about the benefits of treatment further prevent these individuals from undergoing HIV testing. Potential interventions to improve coverage of HIV testing, particularly for these marginalised communities, include expansion of home-based testing and self-testing as well as community engagement to destigmatise HIV. Similar challenges exist in ensuring linkage to care, initiation of therapy and long-term adherence to treatment to ensure viral suppression, particularly amongst KAP. Considerable effort and investment at all levels, for example by increasing the availability of point-of-care testing and laboratory monitoring, an expanded, well trained health care workforce as well as the use of technology to assist with adherence and programme monitoring, are needed to ensure not only that the global goals of treatment are met but also that long-term adherence to treatment is assured across all infected populations.2