HIV/AIDS prevention, care and treatment in the Region of the Americas: achievements, challenges and perspectives

Freddy Pérez Giovanni Ravasi J.Peter Figueroa Beatriz Grinsztejn Mary Kamb Omar Sued Massimo Ghidinelli About the authors

The world has pledged within the Sustainable Development Goals to end the AIDS epidemic by 2030. In Latin America and the Caribbean in 2015 approximately 2.0 million people were living with HIV and an estimated 100 000 new infections occurred. At the same time, significant progress has been made in the Region of the Americas over the past ten years in expanding access and coverage of HIV care and treatment and in achieving elimination of mother-to-child transmission of HIV and syphilis (11 UNAIDS. Global AIDS Update 2016.Geneva: UNAIDS; 2016. Available from: http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf
http://www.unaids.org/sites/default/file...
, 22 Caffe S, Perez F, Kamb ML, Gomez Ponce de Leon R, Alonso M, Midy R, Newman L, Hayashi C, Ghidinelli M. Cuba Validated as the first country to eliminate mother-to-child transmission of Human Immunodeficiency Virus and congenital syphilis: Lessons learned from the implementation of the global validation methodology. Sex Transm Dis. 2016 (12):733-736.). Regarding HIV prevention, stigma and discrimination, new regional elimination targets have also been developed and endorsed (33 Pan American Health Organization. Washington, DC: PAHO; 2005. Regional HIV/STI plan for the health sector 2006–2015. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=298&lang=en
http://www.paho.org/hq/index.php?option=...
). However, challenges still persist; among them, a 3% increase in the rate of new HIV infections in the Region between 2010 and 2015 (44 UNAIDS: Prevention Gap Report. (2016) Available from: http://www.unaids.org/en/resources/documents/2016/prevention-gap
http://www.unaids.org/en/resources/docum...
).

This special issue on HIV/AIDS prevention, care and treatment in the Region of the Americas: achievements, challenges and perspectives provides an opportunity to present the current response to HIV/AIDS in the Region with a focus on three main areas: HIV prevention, HIV care and treatment, and the elimination of mother-to-child transmission of HIV and congenital syphilis. A call for papers was issued in early 2016, and 12 articles were selected for publication—nine original research papers, one brief communication, one review, and one opinion and analysis article. The papers represent seven different countries as well as an overview of the Caribbean sub-region.

A successful HIV prevention program requires a combination of structural, biomedical, and behavioral interventions that are mutually reinforcing, continually evaluated, and tailored to the needs and risks of specific key populations and others who are vulnerable to infection. Previous reports have shown the importance of combination prevention strategies (55 Vermund SH, Hayes RJ. Combination prevention: new hope for stopping the epidemic. Curr HIV/AIDS Rep. 2013 (2):169-86). The special issue addresses this by focusing on HIV prevention strategies available for men who have sex with men in the United States (66 Shrestha R, Sansom S, Purcell D. Assessing HIV acquisition risks among men who have sex with men in the United States of America. Rev Panam Salud Publica. 2016;40(6):474-8.), as well as the social vulnerability of transgender persons (77 Ferreira Jr S, Francisco PMSB, Nogueira PA. Perfil de travestis e transgêneros: tuberculose e HIV/Aids na cidade de São Paulo. Rev Panam Salud Publica. 2016;40(6):410-7.). Both papers highlight the need for tailored interventions that take into account local epidemiological contexts.

The HIV care continuum is a framework that models the dynamic stages of HIV care and is an important tool to measure progress in population-level estimates of program coverage from diagnosis to viral suppression. The special issue focuses on HIV care and treatment by addressing the HIV care continuum through studies that look at risk factors for delays and losses to follow-up among the different stages of care in Brazil (88 MacCarthy S, Hoffmann M, Nunn A, Silva LAV, Dourado I. Barriers to HIV testing, linkage to care, and treatment adherence: a cross-sectional study from a large urban center of Brazil. Rev Panam Salud Publica. 2016;40(6):418-26.), and describes the continuum of care in the Bahamas and in the city of Buenos Aires, Argentina (99 Forbes NM, Johnson G, Mortimer A, Martin I, Frankson M, Johnson K, et al. The HIV continuum of care in the Bahamas in 2014. Rev Panam Salud Publica. 2016;40(6):443-7., 1010 Cesar C, Blugerman G, Valiente JA, Rebeiro P, Sued O, Fink V, et al. The HIV care cascade in Buenos Aires, Argentina: results in a tertiary referral hospital. Rev Panam Salud Publica. 2016;40(6):448-54.). Other researchers in this issue present a review of the HIV response in the Caribbean focusing on the epidemiology, prevention, and the continuum of care and treatment (1111 Gebre Y, Forbes NM, Peters A. Review of HIV treatment progress, gaps and challenges in the Caribbean, 2005-2015. Rev Panam Salud Publica. 2016;40(6):468-73.).

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission of HIV and other infections. A recent review highlighted the importance of integrated services as well as improved counseling methods to help women choose and use an effective birth control method (1212 Lopez LM, Grey TW, Chen M, Denison J, Stuart G. Behavioral interventions for improving contraceptive use among women living with HIV. Cochrane Database Syst Rev. 2016;(8):CD010243). To this end, an opinion and analysis paper explores the special issue’s focus on accelerating progress toward the elimination of mother-to-child transmission of HIV and congenital syphilis and brings attention to the importance of contraception services in order to meet the family planning needs of women living with HIV and to prevent transmission of HIV or syphilis during pregnancy (1313 Gómez Suárez M. Satisfacción de necesidades de anticoncepción en mujeres positivas al VIH: efecto sobre la eliminación de la transmisión vertical del virus. Rev Panam Salud Publica. 2016;40(6):479-84.). With rising use in effective interventions against pediatric HIV infection in the Region, the number of infants infected with HIV has declined. However, the number of uninfected infants exposed to HIV during pregnancy continues to rise. The health outcomes of this pediatric population remain to be fully described (1414 Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination. Lancet Infect Dis. 2016 Jun;16(6):e92-e107. doi: 10.1016/S1473-3099(16)00055-4. Review.
https://doi.org/10.1016/S1473-3099(16)00...
). An original research article from Jamaica shows that infectious disease morbidity increased in a cohort of HIV-exposed, uninfected, non-breastfed infants (1515 Pierre RB, Fulford TA, Lewis K, Palmer P, Walters C, Christie CDC. Infectious disease morbidity and growth among young HIV-exposed uninfected children in Jamaica. Rev Panam Salud Publica. 2016;40(6):401-9.). Another paper provides information on HIV and syphilis co-infection among pregnant women in Porto Alegre, Brazil, and emphasizes the role of social vulnerability (1616 Acosta LM, Tonantzin RG, Barcellos NT. Coinfecção HIV/Sífilis na gestação e transmissão vertical do HIV: um estudo a partir de dados da vigilância epidemiológica. Rev Panam Salud Publica. 2016;40(6):435-42.). Universal HIV and syphilis screening of pregnant women is recommended as part of basic antenatal care. Rapid, specific and validated point-of-care syphilis tests have been developed and successfully implemented in a variety of clinical settings (1717 Tucker JD, Bu J, Brown LB, Yin YP, Chen XS, Cohen MS. 2010. Accelerating worldwide syphilis screening through rapid testing: a systematic review. Lancet Infect Dis 10:381–386.). Two papers from Colombia provide information on this topic. One explores the effectiveness and safety of dual rapid tests on a single device compared to single tests for HIV and syphilis in pregnant women, and the second, a qualitative study, evaluates the acceptability of point-of-care testing in routine antenatal services (1818 Gaitan-Duarte HD, Newman L, Laverty M, Habib N, Gonzalez-Gordon LM, Ángel-Müller E et al. Comparative effectiveness of single and dual rapid diagnostic tests for syphilis and HIV in antenatal care services in Colombia. Rev Panam Salud Publica. 2016;40(6):455-61., 1919 Ochoa-Manjarrés MT, Gaitán-Duarte H, Caicedo S, Gomez B, Pérez F. Introducción de pruebas rápidas para sífilis y VIH en el control prenatal en Colombia: análisis cualitativo. 2016;40(6):462-7.). The quality of the data used to monitor progress and evaluate impact of prevention of mother-to-child transmission programs requires the existence of an adequate system to document and monitor the status of the elimination of mother-to-child transmission impact and coverage indicators. Finally, another paper in this special issue provides results of a Brazilian study evaluating the quality of the information system on HIV/AIDS among pregnant women in the state of Rio Grande do Norte, which highlights the need to invest in infrastructure and training (2020 Meirelles MQB, Lopes AKB, Lima KC. Vigilância epidemiológica de HIV/Aids em gestantes: uma avaliação acerca da qualidade da informação disponível. Rev Panam Salud Publica. 2016;40(6):427-34.).

The vigorous response to the HIV epidemic by the Region of the Americas thus far has led to unprecedented advancements in programs and declines in infections. However, the results of these studies make it clear that it is necessary to address the health needs of the transgender population, increase the proportion of people living with HIV who remain engaged at each step of the HIV treatment cascade, consider the health needs of HIV-exposed infants and introduce and or scale up HIV and syphilis rapid testing as part of the routine package of antenatal care services available for all pregnant women. In addition, key populations continue to be disproportionally affected by HIV disease and face considerable stigma and discrimination, both at the community level and in accessing health services. Although pre-exposure prophylaxis demonstration projects are starting to be implemented in the Region (2121 Ravasi G, Grinsztejn B, Baruch R, Guanira JV, Luque R, Cáceres CF, Ghidinelli M. Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America. J Int AIDS Soc. 2016;19 (Suppl 6):21113.), HIV combination prevention strategies need to be considerably enhanced, especially among young people and those most at risk. Additionally, more efforts supporting progress in elimination of mother-to-child transmission of HIV, syphilis and additional diseases (i.e., perinatal hepatitis B and Chagas disease) are required—vulnerable populations’ access to these services is a priority. Overall, there is a strong need to evaluate and document the effectiveness of HIV interventions in order to identify best practices and disseminate the valuable lessons already learned to allow more effective scale-up of programs in the Region. We hope that this special issue will provide a meaningful contribution toward this goal.

REFERENCES

  • 1
    UNAIDS. Global AIDS Update 2016.Geneva: UNAIDS; 2016. Available from: http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf
    » http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf
  • 2
    Caffe S, Perez F, Kamb ML, Gomez Ponce de Leon R, Alonso M, Midy R, Newman L, Hayashi C, Ghidinelli M. Cuba Validated as the first country to eliminate mother-to-child transmission of Human Immunodeficiency Virus and congenital syphilis: Lessons learned from the implementation of the global validation methodology. Sex Transm Dis. 2016 (12):733-736.
  • 3
    Pan American Health Organization. Washington, DC: PAHO; 2005. Regional HIV/STI plan for the health sector 2006–2015. Available from: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=298&lang=en
    » http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&Itemid=270&gid=298&lang=en
  • 4
    UNAIDS: Prevention Gap Report. (2016) Available from: http://www.unaids.org/en/resources/documents/2016/prevention-gap
    » http://www.unaids.org/en/resources/documents/2016/prevention-gap
  • 5
    Vermund SH, Hayes RJ. Combination prevention: new hope for stopping the epidemic. Curr HIV/AIDS Rep. 2013 (2):169-86
  • 6
    Shrestha R, Sansom S, Purcell D. Assessing HIV acquisition risks among men who have sex with men in the United States of America. Rev Panam Salud Publica. 2016;40(6):474-8.
  • 7
    Ferreira Jr S, Francisco PMSB, Nogueira PA. Perfil de travestis e transgêneros: tuberculose e HIV/Aids na cidade de São Paulo. Rev Panam Salud Publica. 2016;40(6):410-7.
  • 8
    MacCarthy S, Hoffmann M, Nunn A, Silva LAV, Dourado I. Barriers to HIV testing, linkage to care, and treatment adherence: a cross-sectional study from a large urban center of Brazil. Rev Panam Salud Publica. 2016;40(6):418-26.
  • 9
    Forbes NM, Johnson G, Mortimer A, Martin I, Frankson M, Johnson K, et al. The HIV continuum of care in the Bahamas in 2014. Rev Panam Salud Publica. 2016;40(6):443-7.
  • 10
    Cesar C, Blugerman G, Valiente JA, Rebeiro P, Sued O, Fink V, et al. The HIV care cascade in Buenos Aires, Argentina: results in a tertiary referral hospital. Rev Panam Salud Publica. 2016;40(6):448-54.
  • 11
    Gebre Y, Forbes NM, Peters A. Review of HIV treatment progress, gaps and challenges in the Caribbean, 2005-2015. Rev Panam Salud Publica. 2016;40(6):468-73.
  • 12
    Lopez LM, Grey TW, Chen M, Denison J, Stuart G. Behavioral interventions for improving contraceptive use among women living with HIV. Cochrane Database Syst Rev. 2016;(8):CD010243
  • 13
    Gómez Suárez M. Satisfacción de necesidades de anticoncepción en mujeres positivas al VIH: efecto sobre la eliminación de la transmisión vertical del virus. Rev Panam Salud Publica. 2016;40(6):479-84.
  • 14
    Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination. Lancet Infect Dis. 2016 Jun;16(6):e92-e107. doi: 10.1016/S1473-3099(16)00055-4. Review.
    » https://doi.org/10.1016/S1473-3099(16)00055-4
  • 15
    Pierre RB, Fulford TA, Lewis K, Palmer P, Walters C, Christie CDC. Infectious disease morbidity and growth among young HIV-exposed uninfected children in Jamaica. Rev Panam Salud Publica. 2016;40(6):401-9.
  • 16
    Acosta LM, Tonantzin RG, Barcellos NT. Coinfecção HIV/Sífilis na gestação e transmissão vertical do HIV: um estudo a partir de dados da vigilância epidemiológica. Rev Panam Salud Publica. 2016;40(6):435-42.
  • 17
    Tucker JD, Bu J, Brown LB, Yin YP, Chen XS, Cohen MS. 2010. Accelerating worldwide syphilis screening through rapid testing: a systematic review. Lancet Infect Dis 10:381–386.
  • 18
    Gaitan-Duarte HD, Newman L, Laverty M, Habib N, Gonzalez-Gordon LM, Ángel-Müller E et al. Comparative effectiveness of single and dual rapid diagnostic tests for syphilis and HIV in antenatal care services in Colombia. Rev Panam Salud Publica. 2016;40(6):455-61.
  • 19
    Ochoa-Manjarrés MT, Gaitán-Duarte H, Caicedo S, Gomez B, Pérez F. Introducción de pruebas rápidas para sífilis y VIH en el control prenatal en Colombia: análisis cualitativo. 2016;40(6):462-7.
  • 20
    Meirelles MQB, Lopes AKB, Lima KC. Vigilância epidemiológica de HIV/Aids em gestantes: uma avaliação acerca da qualidade da informação disponível. Rev Panam Salud Publica. 2016;40(6):427-34.
  • 21
    Ravasi G, Grinsztejn B, Baruch R, Guanira JV, Luque R, Cáceres CF, Ghidinelli M. Towards a fair consideration of PrEP as part of combination HIV prevention in Latin America. J Int AIDS Soc. 2016;19 (Suppl 6):21113.
Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org