6.5 Proportion of population with advanced HIV infection with access to antiretroviral drugs

Modified on 2012/11/06 09:03 by MDG Wiki Handbook — Categorized as: Goal 6

Contents

GOAL AND TARGET ADDRESSED

Goal 6. Combat HIV/AIDS, malaria and other diseases
Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it

DEFINITION AND METHOD OF COMPUTATION

Definition
The proportion of eligible adults and children living with HIV currently receiving antiretroviral therapy is defined as the percentage of adults and children who are currently receiving antiretroviral therapy (ART) of all adults and children who are eligible for ART.

Concepts
Human immunodeficiency virus (HIV) is a virus that weakens the immune system, ultimately leading to the Acquired immunodeficiency syndrome (AIDS) . HIV destroys the body’s ability to fight off infection and disease, which can ultimately lead to death. Infections associated with severe immunodeficiency are known as “opportunistic infections”, because they take advantage of a weakened immune system. Without treatment, average survival from the time of infection is about 10.5 years for males and 11.5 years for females. Access to treatment is uneven, and no vaccine is currently available.

Antiretroviral therapy (ART) consists of the use of at least three antiretroviral (ARV) drugs to maximally suppress HIV and stop the progression of HIV disease.

Acquired immunodeficiency syndrome (AIDS) refers to the most advanced stages of HIV infection. AIDS is defined clinically by the occurrence of any of more than 25 related opportunistic infections or cancers in a person with serological evidence of HIV infection. An immunological diagnosis of AIDS can also be made if the CD4 count is less than 200 cells per mm3 in an HIV-infected adult (for AIDS diagnosis in children see: http://www.who.int/hiv/pub/vct/hivstaging)

Eligible for ART are those with advanced HIV infection requiring antiretroviral therapy. This is based on recommendations by WHO which were updated in 2010. For example, WHO recommended in 2010, based on new evidence, that the CD4 threshold at which antiretroviral therapy is deemed necessary for adults to be changed from 200 cells per mm3 to 350 cells per mm3. Eligibility criteria for initiating antiretroviral therapy among infants and children are in accordance with WHO treatment guidelines for infants and children.

Method of computation
This indicator is calculated by dividing the number of adults and children in need for ART who receive it by the total number of adults and children with HIV eligible for ART and multiplying by 100.

RATIONALE AND INTERPRETATION

As the HIV epidemic matures, increasing numbers of people are reaching advanced stages of HIV infection. ART has been shown to reduce mortality among those infected and efforts are being made to make it more affordable to all of those in need. This indicator assesses progress toward providing ART to all eligible people.

SOURCES AND DATA COLLECTION

Numbers of adults and children receiving antiretroviral therapy are derived from national programme reporting systems, aggregated from health facilities or other service delivery sites. Health facility reports compile data from facility registers and/or reports from drug supply management systems. ART includes drugs received during the last month of a reporting period. External validation of these figures can also be carried out with data from pharmaceutical companies when available. Some countries have developed their own methods of estimating the number of people who need antiretroviral therapy. In some cases, these estimates are based only on registered HIV cases and therefore do not account for people with HIV who are unaware of their HIV status.

At the international level, UNAIDS and WHO have developed modelling methods to generate country estimates of the magnitude of the epidemic and key impact indicators, including mortality. Treatment needs are estimated by taking into consideration epidemiological surveillance data, adult HIV prevalence over time, average survival time of people living with HIV with and without antiretroviral therapy, and average time between seroconversion and eligibility for antiretroviral therapy.

The total number of adults and children with HIV who need antiretroviral therapy is generated using a standardized statistical modelling approach. The estimation of the number of adults with advanced HIV infection who should start treatment is based on the assumption that the average time from HIV seroconversion to eligibility for antiretroviral therapy is eight years and, without antiretroviral therapy, the average time from eligibility to death is about three years.

Country generated data may differ from estimates by UNAIDS/WHO. National capacity building in the use of the modelling methods has been supported by a global series of training workshops which take place biennially. These workshops bring participants up-to-date with the latest developments in new data collection and build capacity in countries to produce updated estimates. Data inputs to the models are gathered at the national level, for example HIV seroprevalence inputs are from national sentinel HIV surveillance data and national prevalence surveys; population inputs are from national data on the size of groups with high-risk behaviours and estimates of adult population by administrative sub-regions; inputs on treatment needs are from national data on the distribution of CD4 counts (a measure of immune system strength) in adults starting ART per year; and inputs on treatment coverage are from national data on the number of adults and children receiving ART by age group, by year, and by first and second regimens. The large majority of low- and middle income countries now use the above models.

DISAGGREGATION

Treatment data are available disaggregated by sex for most countries. Further breakdowns are recommended by age, such as those below the age of 15 and those ages 15 and above. The group below the age of 15 can be further disaggregated into those below the age of 1, 1–4 and 5–15 years of age. If available, treatment data can be disaggregated by 1st and 2nd line regimens, the provision of treatment through the private or public sector, and by the most-at-risk populations (i.e. sex workers, injecting drug users, and men who have sex with men).

COMMENTS AND LIMITATIONS

Estimates of the number of people receiving antiretroviral therapy can be uncertain in countries that have not established regular reporting systems for recording people who initiate treatment for the first time; rates of adherence among people who receive treatment; numbers of people who discontinue treatment; and numbers of people who die while undergoing treatment.

The reported number of people on antiretroviral therapy carries uncertainties as well. Programme monitoring systems need to be further developed to increase accuracy. For example, some patients pick up several months of antiretroviral drugs during one visit to a treatment centre, which could include antiretroviral therapy for the last month of the reporting period, but might not be recorded in the patient register as visits for the last month of the reporting period. Efforts should be made to account for these patients, as they need to be included in the calculation of the indicator.

Although this indicator allows trends to be monitored over time, it does not attempt to distinguish between the different types of treatment regimens available nor does it measure the cost, quality or effectiveness of treatment. Antiretroviral therapy for post-exposure prophylaxis is not included either.

GENDER EQUALITY ISSUES

Equity in treatment access for women living with HIV has been a concern, given the general social and economic inequities between women and men, as well as the greater biological risk of HIV infection that women face relative to men. Available data suggest that overall women are not disadvantaged in access to antiretroviral therapy. For example, data from 109 countries reveal that, in 2010, 58 per cent of adults receiving antiretroviral therapy were female, even though women represented 53 per cent of the people in need.

Most countries do not report gender breakdowns for the under 15 age group.

DATA FOR GLOBAL AND REGIONAL MONITORING

WHO, UNAIDS and the United Nations Children’s Fund (UNICEF) are responsible for reporting data for this indicator at the international level, and have been compiling country specific data since 2003.

Data are gathered from the most recent reports from health ministries or from other reliable sources in the countries, such as bilateral partners, foundations and nongovernmental organizations that are major providers of treatment services. Countries report to the international system as part of the Global AIDS Progress Reporting of the 2011 Political Declaration on HIV/AIDS (former United Nations General Assembly Special Session on HIV/AIDS (UNGASS) reporting).

Specialized software is used to generate uncertainty ranges around estimates for antiretroviral therapy need. Depending on the quality of surveillance data, the ranges for some countries can be large. Uncertainty ranges around levels of treatment coverage are based on uncertainty ranges around the need estimates.

Regional and global estimates are calculated as weighted averages of country level indicators where the weights correspond to each country’s share of the total number of people needing antiretroviral therapy. Although WHO and UNAIDS collect data on the number of people receiving antiretroviral therapy in high-income countries, no need numbers have been established for these countries. Aggregated coverage percentages are based solely on low- and middle-income countries.

SUPPLEMENTARY INFORMATION



EXAMPLES



REFERENCES

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WORLD HEALTH ORGANIZATION (2010). Antiretroviral therapy for HIV infection in infants and children: Towards universal access. Recommendations for a public health approach: 2010 revision. Geneva. Available from http://whqlibdoc.who.int/publications/2010/9789241599801_eng.pdf

WORLD HEALTH ORGANIZATION (2010). Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Towards universal access. Recommendations for a public health approach: 2010 revision. Geneva. Available from http://whqlibdoc.who.int/publications/2010/9789241599818_eng.pdf