Globally 37 million people live with HIV, 70% of them live in Africa: Since the start of the epidemic in the 1980s 77 million people have become infected with HIV.Important advances have been made in recent years. In 2017 close to a million people died from AIDS related diseases, 50% fewer than at the height of the epidemic in 2004. In 2017, 2 million new HIV infections were recorded; that is 47% less than in 1996. The widespread availability of anti-retroviral (ARV) therapy over the past decade has made a dramatic difference in the survival and transmission rates. Following the global scale-up an estimated 59% of people living with HIV now receive ARV therapy. In 2014, UNAIDS and partners launched the 90–90–90 targets; the target is to diagnose 90% of all HIV-positive persons, provide ARV therapy for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.
Current ARV therapies involve life-long treatment with a minimum of 3 drugs. This is a challenge on the personal patient level, but also at the level of health systems.
Médecins Sans Frontières (MSF) has been treating people infected with HIV since 2000. Alongside MSF, Epicentre has contributed by conducting research projects that demonstrate to the Ministries of Health, donors and the scientific community the feasibility of treating high number of patients in resource-limited settings.
Speeding up access to test results, speeding up start of treatment.
Point of Care (POC) viral load monitoring in Malawi; Early Infant Diagnosis (EID) in Uganda
To reduce the number of new HIV infections early detection and the prescription of effective treatments is important, especially among HIV-infected mothers and their new-borns. In addition, it is important to monitor the treatments effectiveness; an ineffective treatment should be detected early so that the combination of drugs can be adjusted, i.e a switch to 2nd or 3rd line treatment. This detection is best not based on a sole clinical assessment of a patient’s condition as this is often too late. The current gold standard tool to monitor the treatment effectiveness is to measure the HIV viral load. A suppressed viral load indicates that the regimen prescribed is working well and that virus cannot be transmitted.
Measuring viral load involves complex equipment capable of performing so-called PCR tests, whereby copies of the virus can be quantified. Operating this equipment required high-level infrastructure and qualified technicians, which is why in low- and middle-income countries these are typically located in centralized laboratories. This is an impediment to rapid access to results for patients and clinicians alike.
In recent years, Point-Of-Care (POC) devices have been developed and are proving to be a good tool in settings where complex technology is not easy to implement. POC devices permit a same day result opposed to several weeks, sometimes months. This same day result allows prompt action, such as adherence counselling, switch to 2nd or 3rd line regimen.
In Malawi and Uganda Epicentre has had research projects with SAMBA (Simple Amplification Based Assay), one such recent POC method that can detect and monitor early HIV infection in newborns exposed to HIV through their mothers during pregnancy. Early Infant Diagnosis (EID) test results can be made available within a day and treatment, such as ARV initiation, can be started promptly. Viral load measurement through this method also helps to monitor the effectiveness of the ART regimen so that adjustments can be made if necessary.
Directing patients to the optimal treatment regimen
Research into viral load and drug susceptibility testing (DST)
By measuring viral load, the effectiveness of ARV treatment can be assessed. If it becomes clear the patient’s virus is resistant to the ARV regimen, and treatment is failing, it is essential to change the drug combination that make up the treatment, in part or in whole. However, in the settings where MSF works, the number of ARV drugs available is limited, and consequently, so are the number of combinations. Epicentre has conducted several cohort and cross-sectional studies that demonstrate the need for simpler and more accessible Drug Sensitivity Testing techniques to identify effective ARV drugs and providing the evidence base for MSF's advocacy on this issue and highlighting the difficulty of accessing in particular 3rd line ARV drugs.
Improving adherence to treatment
Targeting particular age groups such as adolescents
ARV therapy is a lifelong treatment consisting of at least 3 drugs and is sometimes accompanied by short and/ or long-term side effects. To avoid development and spread of drug-resistant HIV, it is crucial that patients strictly comply with the treatment requirements. This is why HIV management programs need to support patients, because, although patients understand the importance of regular treatment, it is often hard to continue to adhere to a treatment that can have such severe constraints. Epicentre conducted qualitative studies highlighting these constraints faced by patients. The focus has been particularly on adolescents for whom adherence is especially difficult and who are even more susceptible to wanting to avoid the social stigma of HIV and on long-term ART patients who may face similar and other difficulties.
The aim is to reduce non-compliance that contributes to the emergence of drug-resistance requiring a switch to more expensive 2nd or 3rd line treatments, or, even worse run out of treatment options altogether. These studies have contributed to reveal reasons for poor compliance and helped MSF programs to address these issues
Assessing Cascade of Care
Population level studies on prevalence and incidence
Epicentre has conducted population level studies to assess ART programs after several years. Several questions can be addressed with such studies: HIV prevalence and incidence, level of awareness HIV status of the population, linkage to care, viral load suppression at population level. These are key indicators to assess the so-called cascade of care. Progress can be measured of the different steps in HIV treatment and care, gaps can be identified, and goals can be formulated.
In some cases Epicentre has been able to conduct surveys before and after an MSF intervention so that results can be measured.