- Evolution of the WHO antiretroviral treatment guidelines
WHO developed the first guidelines on ART for HIV infection in adults and adolescents in 2002 [14]. These supported the launch, by WHO and UNAIDS, of the “3 by 5” initiative in December 2003, with the objective to provide ART to three million PLHIV by the end of 2005. The “3 by 5” initiative was a step towards the goal of making universal access to HIV/AIDS prevention and treatment for all who need them as a human right [15]. At the September 2005 General Assembly High-Level Meeting on HIV/AIDS, United Nations Member States agreed to work towards the goal of “universal access to comprehensive prevention programmes, treatment, care and support” by 2010 [16]. In the June 2006 meeting of the United Nations General Assembly, a resolution was passed towards universal access to HIV/AIDS services [17].
Subsequently, the ART guidelines were comprehensively updated in 2006. The key principles of a public health approach were articulated and expanded in these guidelines: simplified and standardized regimens, including approaches to service delivery, in particular to task shifting, decentralisation, and integration of HIV treatment and care [18, 19]. ART guidelines were further revised to expand the eligibility threshold in 2010 [20]. WHO revised and combined these ART guidelines with other ARV-related guidance into consolidated guidelines in 2013 and 2016 [21, 22].
The guidelines have evolved in response a number of advances in the HIV treatment landscape: new antiretroviral drugs and combinations of them have been developed;17 the average cost of first-line therapy has been reduced to less than US$100 per patient per year, from an initial cost of over $10, 000 [23]; point-of-care diagnostics for CD4 cell count, viral load testing, and early infant diagnosis have become available [24]; and the benefit of ARV drugs for HIV prevention has been realised [25, 26]. The implementation of the guidelines benefited from global leadership, strong partnership and advocacy; country adaptation and implementation; a reliable supply of medicines and diagnostics; identification and application of new knowledge at national and global levels [15, 19-22].
Table 1 illustrates the evolution of one of the recommendations (when to start ART with a first-line regimen) of these guidelines. The table shows that the guidelines have evolved from “treating the sickest” to “treating all” [15, 19-22].
Table 1: Evolution of the antiretroviral treatment guidelines: when to start first-line treatment
In these initiatives, road maps and guidelines, “access” has been considered to represent a broad concept, which measures three dimensions: (1) “availability” (defined in terms of reachability, affordability and acceptability of services that meet a minimum standard of quality), key services available, affordable and acceptable is an essential precondition for universal access; (2) “coverage” (defined as the proportion of a population needing an intervention who receive it); and (3) “impact” (defined as reduced new infection rates or as improvements in survival) [27]. We will be focusing on the second and third dimensions of “access”, as they not only are higher level indicators (outcome and impact), but also implicitly provide evidence on successes and challenges in the first dimension: there is no “coverage” and “impact” without “availability”.
- Scaling up of antiretroviral treatment: Coverage
The number of PLHIV on ART increased from two million in 2005 to more than 23.3 million in 2018; an increase in ART coverage from less than 7% in 2005 to close to 62% in 2018 (Table 2) [28]. By the end of 2018, it was estimated that 79% of PLHIV globally knew their HIV status; among those who knew their HIV status, 78% were accessing ART; and, 86% of people accessing ART had suppressed viral loads [28].
Countries are used to reporting the number of people on ART as ever started on ART or currently on ART. However, the databases from UNAIDS and WHO do not provide separate figures on these. Similarly, we were not able to compile and present the data on second-line ART, as it was either not reported by countries or the report was incomplete.
Table 2: Scaling up of antiretroviral treatment between 2000 and 2018
- New HIV infections and deaths: impact
Expanding the eligibility criteria for ART and using ARV drugs for prevention create opportunities to reduce HIV transmission and save lives. With the scale-up of ART, PLHIV can expect to have a life expectancy similar to that of the general population. The number of new HIV infections dropped by 39% from 2.8 million in 2005 to 1.7 million in 2018. On the other hand, the number of deaths increased from 1.4 to 1.7 million between 2000 and 2005; afterwards, it dropped by 55% from 1.7 million in 2005 to 0.77 million in 2018 [29].
Figure 1: Number of new HIV infections and deaths in people living with HIV, 2000-2018
- Equity in antiretroviral treatment coverage
In spite of the success in increasing ART coverage in all populations and locations, progress varies by region: in eastern and southern Africa, there has been much more gain than other regions; western and central Europe and North America have nearly reached the targets; On the other hand, eastern Europe and central Asia, the Middle East and North Africa and western and central Africa regions are considerably off track. For instance, in eastern and southern Africa, 62% of children were accessing ART while 28% of children were accessing ART in western and central Africa in 2018 [28].
These gaps remain challenges for the ART program at global, regional and national levels. Inequity continues to be a problem and even widened over time (table 3). This trend has followed the changes in the ART guidelines for treatment initiation. The expanded ART eligibility criteria towards universal ART overlaps with the widened inequity (among population groups (female versus male and adults versus children) and across locations).
Table 3: Changes in differences in ART coverage between adults and children and female and male people living with HIV, 2010-2018
In Ethiopia, ART coverage increased in all regions between 2006 and 2017. ART coverage has converged in all regions, including Gambella region with the highest prevalence of HIV in the country (Figure 2). The progress in ART coverage in the country and its regions is associated with the increased HIV testing coverage over time. The differences in ART coverage among regions can also be explained by the variability in HIV testing coverage across regions (Figures 2 and 3). Among regions which contributed more than 90% of the HIV burden in the country, ART coverage is correlated with HIV testing coverage with Pearson correlation coefficient of 0.74.
Figure 2: ART coverage at regional level in Ethiopia, 2005, 2010, 2013 and 2017
Figure 3: HIV testing coverage at regional level in Ethiopia, 2005, 2011 and 2016