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90? 90? 90? Ending the HIV pandemic has scary obstacles, warns former WHO chief!

By Gus Cairns

The large view of one homeme is usually the tip of the iceberg
The great vision of one man is usually the tip of the iceberg

The difficulty of bringing the HIV to "zero" should not be underestimated, says Kevin de Cock, former director of HIV prevention and response at the World Health Organization (WHO) earlier this month at a meeting of the European AIDS Clinical Society (EACS) in Brussels.

EACS held this meeting to formulate nNew standards for response and care for HIV ns Europe. The themes of the meeting will be summarized in another report, but Dr. de Cock, who led the Ebola program in Liberia, now heads the Center for Disease Control of the HIV program in Kenya, set the tone of the presentation to a broader plenary session on the first night. This event addressed everything from a global climate change to Africa's political future as issues that could influence and challenge future progress not only in HIV care, but generically, Global Health Care.

What does "close to zero"?

dr-zero

Dr de Cock had some criticism of "90-90-90" as an influence on the target, by the way people envisioned the possibility of ending the HIV epidemic in such a short time.

This objective aims at overall achievement of 72% of all people with HIV in treatment and viral load suppressed in 2020, and to 86% to 2030.

.

"90 / 90 / 90 was developed as a" defense tool, "he said," it's a yardstick to measure progress. However I do not have the notion of how he slipped into a policy and resulted in a number of technical papers on how to get there. "

He warned against too literal interpretation of HIV infection "drain" to zero to 2030.

kevin-of-cockHe said he preferred the definition offered by Hillary Clinton, and her definition, the International AIDS Conference in Durban last July, was that "Practically no child should be born with HIV"; that adolescents and young adults worldwide be in a "significantly lower risk" of becoming infected than it is today; and that all people with HIV should have universal access to treatment, to prevent disease and subsequent transmissions. "That there was almost no deaths."

De Cock said, "it is accessible to 2030."

What we have achieved in the field of global health

Political map of the world

Dr De Cock puts the fight against HIV in the context of a much broader, the fight for global health in general. And in this field We had made remarkable progress.

Eg

  • 12,7 million under-five children died in 1990;
  • In 2015 it was "only" six million, despite the increase in population.
  • Infant mortality in Kenya declined from 7,4% per annum to 3,9% during the same period, although the birth rate has increased.
  • An even better method of analysis about direct improvements in health was maternal mortality at birth:
  • Kenya, this had decreased from 0,38 100 for each live births per year in 1990 0,21 for "now" in 2016.

HIV has acted as a trigger for progress toward global health in many and many ways. Indeed, before 2000 "global health" was not a term commonly used to describe a work area - "tropical medicine" was still used before and after, with its focus on specific treatment for specific diseases.

It was the fight for antiretrovirals for Africa and programs designed to provide them with these drugs, such as the emergency plan of the President of the United States (Barak Hussein Obama) for AIDS Relief (PEPFAR) and the Global Fund, who had helped run the plan in a global audience of health care efforts.

Editor's Note Soropositio.Org: The Old and already senescent former President George Bush (father) told the press that "Brazil is willing to scrificar *** *** some lives now (around 2000) many others would be saved ... It's ... it may even be that he was somehow demonic, but surely I and Beto Volpe, Sílvia Almeida Veriano Terto Júnior, Paulo Giacomini and many others would have had very little chance of getting here, even though we have suffered losses exasperating by the way.

However, there were troubling indications that progress not only against HIV but also against diseases associated with it, HIV and not Bush, it must be clarified, may make it a more arduous and steep road ahead. Tuberculosis, for example, had not diminished as much as other diseases.

  • In 2000, had 2,3 million TB deaths, 25% of them in people with HIV;
  • In 2015, this was 1,7 million (26% decline), 29% in people with HIV.

Barriers to 90-90-90: Tests

1teste-fast-hiv-1440x764_c

Talking about the "specific target" _90-90-90_, De Cock said, means proving that these goals have been realistically achieved and you see, from the outset, that it is frustratingly difficult to get to the first 90 "- this being the goal of 90% of all people with HIV diagnosed.

[Translator's Note: ISIS (...) plays from the top of buildings known to people living with HIV. Who will be tested in the context of these? We know about the Asian bloc composed of all that once represented the Union of Soviet Socialist Republics (think of the deplorable ethnic cleansing in Sarajevo); what is known about AIDS in China? In Saudi Arabia? In Iran? In Palestine In Israell in Malaysia or Minsky? How can one be, pardon the bad words, be _temerário_ to the point, based on reading without reflection (the blindingly obvious) that we are "close it." Yes, it is much closer in destructive capacity, those who say that HIV does not cause AIDS and those others who diuturnamente try to raise my "sympathy for mutamba" ...]

In Kenya, between 2004 and 2015, had 6,5 million HIV tests in a country of 44 million people. Three percent of people tested with HIV, which is half of 6% prevalence rate estimated by UNAIDS. And, although it is estimated that 28% of people with HIV are not in care, largely due to lack of diagnosis, and 48% more in higher prevalence of Kenya's provinces. Testing programs for high prevalence of municipalities are not detecting a greater proportion of people than in low prevalence; and yes in reverse.

Testing programs had to be reshaped to focus on testing the most vulnerable populations to HIV, Cock De said. In Kenya as elsewhere, the highest yield of positive tests was in people diagnosed with TB where 18% of TB diagnostic evolved forward to lead to the diagnosis of HIV infection; and yet it is still only 60% of people diagnosed with TB who fail a test for the detection of HIV infection. And around the world and in Europe only 50% of people diagnosed with TB can an anti-HIV test.

the man with no face over dark backgroundEDITOR'S NOTE: AND AN AVATAR SAYS WE ARE NEAR! ... And another, stunned, says that "our health, now that we are HIV positive, will be at a level better than the previous one. It's almost an invitation: Come on! Come on! Having HIV is good for your health! It's just a pill!

Other people with TB, with the highest rate of detection of HIV infections, owe the results from programs that tested everyone admitted as inpatient in the hospital: in PEPFAR-embracing countries, the HIV rate in this group was about of 4,6%. In Africa, a similar rate was observed in men close to the fronts made up of volunteer doctors for male circumcision: And this was important in demonstrating how men were much harder to achieve by HIV testing programs. In countries where there are sexual and reproductive health clinics, testing at these clinics has also yielded high rates of positive HIV serology.

In contrast, tests on mobile ambulatory and initial clinical trials programs had the lowest rates (between 1,5 and 3% in countries covered by PEPFAR). ambulatory tests were by far the most common configuration tests producing the highest absolute number of positive results. However, de Cock claimed that false positive and false negative can become a growing problem in a situation where most people with chronic infection have been diagnosed. A note from the editor to people in emotional crisis for lack of faith in science and in God, atenazadas fault or whatever it is, and who seek to support at all to say that your tests are wrong, the herein false negatives are a reference to people who tested within the window period and eventually present a false negative in a city and, for example, nine days later, the window period already served, responded reagent tisnando the accuracy of these cohorts.

The only way to definitively establish HIV prevalence and its contribution to mortality would be to test each person; and this could only be done ethically by the test of the deceased. De Cock gave some very interesting data from a study in which each of the corpses that came to two mortuaries in Nairobi were tested for HIV.

Although HIV prevalence in both Nairobi and Kenya, which is usually 6%, 20% of all tested cadavers resulted emHIV positive and 30% were female. A quarter of people killed at the age of 25 44 the tested resulted in HIV positive, but even in people over 45 years 15% were positive and the proportion of deaths due to HIV was also 15%. This, despite the fact that an estimated 70% of all people with HIV in Nairobi are on antiretroviral therapy (ART). HIV is therefore also responsible for a disproportionate number of deaths, even in settings where antiretroviral therapy coverage is good.

Barriers to 90-90-90: retention

Queue at a health center waiting for the withdrawal of its antiretroviral drugs (merely illustrative - the reality is much worse?
Queue at a health center waiting for the withdrawal of its antiretroviral drugs (merely illustrative - the reality is much worse)

As for the "second 90", retention in care, this differs immensely between countries, from excellent in some places with HIV "one-stop-shop" services; or deplorably poor in countries where people may need to seek care for different conditions in different locations or have some care and needs supported.

Editor's Note>: "one-stop-shop" is the definition centers where it is testing, diagnosis, clinical care and dispensing condoms and, for best example of this I mention, in São Paulo, the House of AIDS than in far exceeds, at all levels, the deplorable system of things and facts in other hospitals ... on the other hand, today, the day revise this text for publication, my wife and I wandered for four health posts only and only for, in their room, being told that the drugs that are prescription "in the buying process." I am writing in São Paulo, more than ten million people with zero logistics!

Some studies such as ANRS study 12249 ('Test and treat': large study fails to show an impact on new HIV infections)

Tests show that the idea that people tested positive to thereafter forward the clinical for treatment does not always work. There was no doubt that the same day that the revenue from the HAART components were prescribed would cause people to walk back to their homes with their antiretroviral drugs, "and the day they were diagnosed."

Encouraged better retention and adherence, as was done with treatment regimens with single pill, De Cock said. But to ensure a good retention does not have to mean a higher offer intensive support for all patients. However this means offering a stable program and a place to connect or provide relief (such as the House of AIDS support groups) if things go wrong in any and / or any time.

models of care that newly diagnosed patients and those who are starting antiretroviral therapy receive monthly or even based on weekly appointments for the withdrawal of their medications, while people who have been under stable HAART for more than two years received tests and drugs only every six months are already being adopted in Kenya and, in fact, high performance standard countries per capita, mit should be based on a model of differentiated and widely diversified care of interventions to establish the beginning of treatment, lead the person to understand that the treatment is good for him and take him, by the hand, to the responsibility for his well-maintained health and, on the basis of that, to their survival, as advocated by WHO. This should not only consider the frequency of commitments but also where people were found and diagnosed (Hospital? Community Clinic? In your home?) By whom? (Doctor? Nurse? Pharmacist? Point support worker accession?) And with what? (Psychosocial Reviews? Point to support membership? The drug level monitoring?).

Editor's note: With the open ZAP for understanding I have communicated me with Lusophone communities in Africa and not a few ondeeu circumstances I found myself in the need to tell the person that she ran the risk of dying in less than twelve months (not is impossible without treatment) for them to convince the (I want to believe) approaching providers of medical centers and withdraw their medications and unfortunately heard a lot being said: Yeah, you're right. Next week will pass there. And I have to silence before becoming a boring and one block me, the desire to keep any hope of knowing it) the person) if medicating

Barriers to 90-90-90: viral load monitoring and consistency of guidelines

Group-of-medicos

The mention of clinical monitoring leads us to the third "Meta 90":

viral suppression. Here there is a clear barrier to overcome - the continued unavailability of regular viral load tests.

Editor's note: I did not scrutinize it. I went to Google and sought "Antiretroviral missing. Follow this linkIt opens in another window. If you do not want to go there, accept this fact: 246.000 results in Portuguese. They are or have been news in the last, say, ten years. It gives an average of 24.600 per year, which gives about 2.400 news per month (...).

Even in Europe, Serbia is an example of a country that does not offer a viral load test routine - a situation that the EACS conference decided to try to correct. Availability of viral load tests meant nothing if it was irregular, sporadic, or constant with no change in the therapeutic regimen in cases of therapeutic failure, De Cock said. Kenya had relatively high rates of viral load tests for Africa, but factors such as the high cost of 2ª and 3ª drugs conspired with the lack of clarity of clinical guidelines to perpetuate a situation where people were kept on failed schemes by long time resulting in extensive and wide resistance development rate and disastrous treatment failures for these individuals.

People with HIV, he added, are still very often subject to inconsistencies:

Individualized treatment regimens, partly due to the range of antiretroviral drugs available and missing.

"If you have TB, you will receive prescriptions from the same therapeutic regimens if you are in Los Angeles or Malawi," he said. "But trained and trained physicians who will act as violins tuned by the same tuning fork or by exactly the same pitch in all" centers of expertise "that are aware enough to know that medicine is advancing, and that they must search for novelties of times in times (the editor of this site suggests monthly), and in the case of HIV infection, people receive dozens of different regimens. Such "prescription centrifuges" do not help to establish the isonomy of treatment, and this, per seIt is already a displacer factor possibilities for Ninety Triple "

He added that this variety often catalisariam in the face of clear scientific evidence. "I'm upset," he said, "after the beginning of the study all European countries immediately changed their guidelines for the treatment of all patients with the diagnosis."

Em separate presentation, The president of EACS Battegay Manual showed that nine European countries, including some amazing nations such as Ireland and Norway still had guidelines saying that HAART should be started when the CD4 count had fallen below 350 cells / mm3. Editor's note: I am desolate

If even the "treating everyone" is not accessible, De Cock said, "Guidelines should say that universal treatment is the best clinical option and should be designed for all countries."

The opportunities and challenges of the future

hopeful

De Cock has put these challenges in a much wider context, both in Africa and globally. Opportunities for improving health care in low-income countries were not exciting, he said, especially since they were the ones with the highest economic growth - even though economic growth brought with it "Diseases of civilization" as diabetes and hypertension.

Technologies such as mobile phones in Africa have allowed Africans a "leap" of entire generations in technology, said de Cock. Antiretroviral therapy than for health, going direct from health care to major public health programs. Future developments such as points of care, improved diagnoses, and possibly vaccines, could continue this progress.

Against that, however, maintain the health improvements of the last half-century will confront familiar who face daunting barriers: conflict and security; Migration; corruption; resource scarcity and environmental degradation; all these factors hinder the improvement of health and global warming threatening to introduce new infections (would be Zika Vius one?) emerging too much.

The biggest challenge of all, he said, would be in health care a world population that thickens the 7,3 billion (16% of them in Africa) in 2015 to 11,2 billion (40% of them in Africa) in 2100. Why, over time, Lagos and Kinshasa would be two of the largest cities in the world. Have HIV, at least, have been reduced to a rare infection in these urban agglomerations of the future, or will be like us?

claudiusTranslated by Claudio Souza's original in Ending the HIV epidemic faces daunting barriers, former WHO HIV Chief Warns

Reviewed by Mara Macedo in January 2017

The anonymous telephone

Hello .. Good evening. You told me I do a "shit site" with depressing news and I do not put the HIV carrier cheer "up".

Yes, my dear anonymous. I decided that I will not answer unknown numbers and which I will record, in short, all the calls you receive.

But you should also connect to Dr De Cock and say the same thing to him!

You know, I like to give good news and I'm very happy when I find something that gives me joy to publish, like the success of the START Study. Only on this link there are about forty great news and you can click without fear that I respect your vocation to Alice and there are no tricks, you will not read something, how did you even say?

…depressing…

But also read the article posted here, on this page, below this message and stay alert. I'm recording the phone calls. If they are not yours, I'll delete them. Yours….

Well, every action generates a reaction of equal force in the opposite direction ...

But I think you already know that.

Reference

De Cock, K. Quality of Care, a global perspective: the future of quality of care. Presentation at EACS Standard of Care for HIV and coinfections in Europe meeting, Brussels, 2016. See presentation here.

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