Monitoring HIV Treatment and the Health Sector Cascade: From Treatment Numbers to Impact.

Although not originally part of the MDGs, HIV treatment has been at the center of global HIV reporting since 2003, marked by achievement of the target of 15 million people receiving treatment before 2015 and 18.2 million (16.1-19.0 million) by mid 2016. Monitoring of treatment has been strengthened with harmonized partner reporting and accountability with regular, annual reports. Beyond treatment numbers, increasingly measures of treatment adherence, retention and outcomes have been reported though with varying quality and completeness. However, with the sustainable development goals (SDGs), monitoring treatment is changing in three important ways. First, treatment monitoring is shifting from numbers to coverage and gaps in a cascade of services to achieve universal access. Secondly, this requires greater emphasis on disaggregated, individual level patient and case monitoring systems, which can better support linkage, retention and chronic, long term care. Thirdly, the prevention, testing and treatment cascade with a clear results chain, links treatment numbers to impact, in terms of reduced viral load, mortality and incidence. This agenda will require a greater contribution of routine impact evaluation alongside monitoring, with treatment seen as part of a cascade of services to ensure impact on mortality and incidence. In conclusion, the shift from monitoring treatment numbers to treatment linked to universal access to prevention, testing and treatment and impact on mortality and incidence, will be critical to monitor, evaluate, and improve HIV programs as part of the SDGs.

Antiretroviral therapy needs: the effect of changing global guidelines.

BACKGROUND: In 2010 the WHO issued a revision of the guidelines on antiretroviral therapy (ART) for HIV infection in adults and adolescents. The recommendations included earlier diagnosis and treatment of HIV in the interest of a longer and healthier life. The current analysis explores the impact on the estimates of treatment needs of the new criteria for initiating ART compared with the previous guidelines. METHODS: The analyses are based on the national models of HIV estimates for the years 1990-2009. These models produce time series estimates of ART treatment need and HIV-related mortality. The ART need estimates based on ART eligibility criteria promoted by the 2010 WHO guidelines were compared with the need estimates based on the 2006 WHO guidelines. RESULTS: With the 2010 eligibility criteria, the proportion of people living with HIV currently in need of ART is estimated to increase from 34% to 49%. Globally, the need increases from 11.4 million (10.2-12.5 million) to 16.2 million (14.8-17.1 million). Regional differences include 7.4 million (6.4-8.4 million) to 10.6 million (9.7-11.5 million) in sub-Saharan Africa, 1.6 million (1.3-1.7 million) to 2.4 million (2.1-2.5 million) in Asia and 710 000 (610 000-780 000) to 950 000 (810 000-1.0 million) in Latin America and the Caribbean. CONCLUSIONS: When adopting the new recommendations, countries have to adapt their planning process in order to accelerate access to life saving drugs to those in need. These recommendations have a significant impact on resource needs. In addition to improving and prolonging the lives of the infected individuals, it will have the expected benefit of reducing HIV transmission and the future HIV/AIDS burden.

Estimation of antiretroviral therapy coverage: methodology and trends.

PURPOSE OF REVIEW: To present the methodology used to calculate coverage of antiretroviral therapy (ART) and review global and regional trends in ART coverage. RECENT FINDINGS: There has been a steady increase in ART coverage over the last decade with a more rapid increase in recent years. Current estimates of ART coverage are 43% for adults and 38% for children (ages 0-14 years). Methods for calculating coverage rely on good-quality patient monitoring systems in countries, and well informed models are needed to estimate the number of people in need of treatment. SUMMARY: The estimated coverage rates show that ART programs have improved over the past 8 years; however, approximately 58% (53-60%) of those people in need of ART are still not on treatment. High quality data are needed to accurately measure changes in ART coverage.

Forecast of demand for antiretroviral drugs in low and middle-income countries: 2007-2008.

BACKGROUND: Middle and low-income countries have scaled up HIV treatment in the past 5 years. To maintain this effort, information regarding the amounts and types of drugs is needed. Shortages or overstock of active pharmaceutical ingredients make the scale-up efforts more difficult and costly. To inform global planning and implementation, we estimate the volume of current and future demand for active pharmaceutical ingredients for first and second-line antiretroviral drugs. METHODS: Using regression analysis and documented assumptions, we estimated the number of individuals receiving antiretroviral drugs to 2008. The volume of active pharmaceutical ingredients was calculated using two methods: a normative approach modelling implementation of country-specific guidelines, and an empirical model projecting current trends in drug use estimated by a survey of country HIV programmes. RESULTS: The number of patients treated was estimated to reach 3.38 million by the end of 2008, of which 94.6% would be on first-line and 5.4% on second-line treatment. The largest estimated absolute demand volumes for 2008 were for nevirapine, lamivudine, and zidovudine using either approach; the largest proportional increases in 2007-2008, were observed for emtricitabine, tenofovir, indinavir, and nelfinavir. The gap between normative and empirical estimates was greatest (most positive) for tenofovir, zidovudine, didanosine, and smallest (most negative) for saquinavir and nelfinavir. CONCLUSION: A comparison of the results from the normative and empirical demand quantities suggests that more tenofovir, zidovudine and didanosine would be required if national treatment guidelines were fully implemented, whereas the countries seem to be using more saquinavir and nelfinavir than would be required by their current guidelines.

Monitoring the scale-up of antiretroviral therapy programmes: methods to estimate coverage.

This paper reviews the data sources and methods used to estimate the number of people on, and coverage of, antiretroviral therapy (ART) programmes in low- and middle-income countries and to monitor the progress towards the "3 by 5" target set by WHO and UNAIDS. We include a review of the data sources used to estimate the coverage of ART programmes as well as the efforts made to avoid double counting and over-reporting. The methods used to estimate the number of people in need of ART are described and expanded with estimates of treatment needs for children, both for ART and for cotrimoxazole prophylaxis. An estimated 6.5 million people were in need of treatment in low- and middle-income countries by the end of 2004, including 660,000 children under age 15 years. The mid-2005 estimate of 970,000 people receiving ART in low- and middle-income countries (with an uncertainty range 840,000-1,100,000) corresponds to a coverage of 15% of people in need of treatment.