Background
New infections have fallen by 35% since 2000 and AIDS-related deaths by
24%. Some 16 million people are now receiving antiretroviral treatment – more
than 11 million of them in Africa. Ten million men in East- and Southern Africa
have volunteered for medical male circumcision – a procedure that reduces a
man’s risk of contracting HIV by 60%.
But now it’s time to act even more boldly, to take innovative steps so
the world can meet the Sustainable Development Goal target of ending the
epidemic by 2030. This September, world leaders agreed ambitious interim
targets to fast track efforts to end AIDS.
On World AIDS Day, new WHO recommendations will launch to help achieve
these targets. These include the use of innovative HIV testing methods;
customizing treatment approaches to meet the full diversity of people’s needs;
and offering a wider spectrum of prevention options.
Some low- and middle-income countries are already fast-tracking national
AIDS responses. Countries do best when they make substantial domestic
investments, base their HIV health-sector programmes on good data and simplify
prevention and treatment programmes. Twelve countries have ensured that 60% or
more of all people living with HIV are aware of their HIV infection and receive
antiretroviral treatment.
Pioneering countries like these show that the new targets set for ending
AIDS are feasible – even in resource-limited settings.
Key facts
HIV continues to be a major global public health issue, having claimed
more than 34 million lives so far. In 2014, 1.2 [980 000–1.6 million] million
people died from HIV-related causes globally.
There were approximately 36.9 [34.3–41.4] million people living with HIV
at the end of 2014 with 2.0 [1.9–2.2] million people becoming newly infected
with HIV in 2014 globally.
Sub-Saharan Africa is the most affected region, with 25.8 [24.0–28.7]
million people living with HIV in 2014. Also sub-Saharan Africa accounts for
almost 70% of the global total of new HIV infections.
HIV infection is often diagnosed through rapid diagnostic tests (RDTs),
which detect the presence or absence of HIV antibodies. Most often these tests
provide same day test results; essential for same day diagnosis and early
treatment and care.
There is no cure for HIV infection. However, effective antiretroviral
(ARV) drugs can control the virus and help prevent transmission so that people
with HIV, and those at substantial risk, can enjoy healthy and productive
lives.
It is estimated that currently only 53% of people with HIV know their
status. In 2014, approximately 150 million children and adults in 129 low- and
middle-income countries received HIV testing services.
By mid-2015, 15.8 million people living with HIV were receiving
antiretroviral therapy (ART) globally.
Between 2000 and 2015, new HIV infections have fallen by 35%,
AIDS-related deaths have fallen by 24% with some 7.8 million lives saved as a
result of international efforts that led the global achievement of the HIV
targets of the Millennium Development Goals.
Expanding ART to all people living with HIV and expanding prevention
choices can help avert 21 million AIDS-related deaths and 28 million new
infections by 2030.
The Human Immunodeficiency Virus (HIV) targets the immune system and
weakens people's defence systems against infections and some types of cancer.
As the virus destroys and impairs the function of immune cells, infected
individuals gradually become immunodeficient. Immune function is typically
measured by CD4 cell count. Immunodeficiency results in increased susceptibility
to a wide range of infections and diseases that people with healthy immune
systems can fight off.
The most advanced stage of HIV infection is Acquired Immunodeficiency
Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the
individual. AIDS is defined by the development of certain cancers, infections,
or other severe clinical manifestations.
Signs and symptoms
The symptoms of HIV vary depending on the stage of infection. Though
people living with HIV tend to be most infectious in the first few months, many
are unaware of their status until later stages. The first few weeks after
initial infection, individuals may experience no symptoms or an influenza-like
illness including fever, headache, rash or sore throat.
As the infection progressively weakens the immune system, an individual
can develop other signs and symptoms, such as swollen lymph nodes, weight loss,
fever, diarrhoea and cough. Without treatment, they could also develop severe
illnesses such as tuberculosis, cryptococcal meningitis, and cancers such as
lymphomas and Kaposi's sarcoma, among others.
Transmission
HIV can be transmitted via the exchange of a variety of body fluids from
infected individuals, such as blood, breast milk, semen and vaginal secretions.
Individuals cannot become infected through ordinary day-to-day contact such as
kissing, hugging, shaking hands, or sharing personal objects, food or water.
Risk factors
Behaviours and conditions that put individuals at greater risk of contracting
HIV include:
having unprotected anal or vaginal sex;having another sexually
transmitted infection such as syphilis, herpes, chlamydia, gonorrhoea, and
bacterial vaginosis;
sharing contaminated needles, syringes and other injecting equipment and
drug solutions when injecting drugs;
receiving unsafe injections, blood transfusions, medical procedures that
involve unsterile cutting or piercing; and
experiencing accidental needle stick injuries, including among health
workers.
Diagnosis
Serological tests, such as RDTs or enzyme immunoassays (EIAs), detect
the presence or absence of antibodies to HIV-1/2 and/or HIV p24 antigen. When
such tests are used within a testing strategy according to a validated testing
algorithm, HIV infection can be detected with great accuracy. It is important
to note that serological tests detect antibodies produced by an individual as
part of their immune system to fight off foreign pathogens, rather than direct
detection of HIV itself.
Most individuals develop antibodies to HIV-1/2 within 28 days and
therefore antibodies may not be detectable early after infection, the so-called
window period. This early period of infection represents the time of greatest
infectivity; however HIV transmission can occur during all stages of the
infection.
It is best practice to also retest all people initially diagnosed as
HIV-positive before they enrol in care and/or treatment to rule out any
potential testing or reporting error.
HIV testing services
HIV testing should be voluntary and the right to decline testing should
be recognized. Mandatory or coerced testing by a health-care provider,
authority or by a partner or family member is not acceptable as it undermines
good public health practice and infringes on human rights.
Some countries have introduced, or are considering, self-testing as an
additional option. HIV self-testing is a process whereby a person who wants to
know his or her HIV status collects a specimen, performs a test and interprets
the test results in private. HIV self-testing does not provide a definitive
diagnosis; instead, it is an initial test which requires further testing by a
health worker using a national validated testing algorithm.
All HIV testing services must include the 5 C’s recommended by WHO:
informed Consent, Confidentiality, Counselling, Correct test results and
Connection (linkage to care, treatment and other services).
Prevention
Individuals can reduce the risk of HIV infection by limiting exposure to
risk factors. Key approaches for HIV prevention, which are often used in
combination, include:
1. Male and female
condom use
Correct and consistent use of male and female condoms during vaginal or
anal penetration can protect against the spread of sexually transmitted
infections, including HIV. Evidence shows that male latex condoms have an 85%
or greater protective effect against HIV and other sexually transmitted
infections (STIs).
2. Testing and
counselling for HIV and STIs
Testing for HIV and other STIs is strongly advised for all people
exposed to any of the risk factors. This way people learn of their own
infection status and access necessary prevention and treatment services without
delay. WHO also recommends offering testing for partners or couples.
Tuberculosis (TB) is the most common presenting illness among people
with HIV. It is fatal if undetected or untreated and is the leading cause of
death among people with HIV- responsible for 1 of every 3 HIV-associated
deaths. Early detection of TB and prompt linkage to TB treatment and ART can
prevent these deaths. It is strongly advised that HIV testing services
integrate screening for TB and that all individuals diagnosed with HIV and
active TB urgently use ART.
3. Voluntary
medical male circumcision
Medical male circumcision, when safely provided by well-trained health
professionals, reduces the risk of heterosexually acquired HIV infection in men
by approximately 60%. This is a key intervention in generalized epidemic
settings with high HIV prevalence and low male circumcision rates.
4. Antiretroviral
(ART) use for prevention
4.1 ART as
prevention
A 2011 trial has confirmed if an HIV-positive person adheres to an
effective ART regimen, the risk of transmitting the virus to their uninfected
sexual partner can be reduced by 96%. The WHO recommendation to initiate ART in
all people living with HIV will contribute significantly to reducing HIV
transmission.
4.2 Pre-exposure
prophylaxis (PrEP) for HIV-negative partner
Oral PrEP of HIV is the daily use of ARV drugs by HIV-uninfected people
to block the acquisition of HIV. More than 10 randomized controlled studies
have demonstrated the effectiveness of PrEP in reducing HIV transmission among
a range of populations including serodiscordant heterosexual couples (where one
partner is infected and the other is not), men who have sex with men,
transgender women, high-risk heterosexual couples, and people who inject drugs.
In September 2015, WHO published the “Guideline on when to start
antiretroviral therapy and on pre-exposure prophylaxis for HIV”, that
recommends PrEP as a prevention choice for people at substantial risk of HIV
infection as part of combination prevention approaches.
4.3 Post-exposure
prophylaxis for HIV (PEP)
Post-exposure prophylaxis (PEP) is the use of ARV drugs within 72 hours
of exposure to HIV in order to prevent infection. PEP includes counselling,
first aid care, HIV testing, and administering of a 28-day course of ARV drugs
with follow-up care.
Updated WHO guidelines issued in December 2014 recommend PEP use for
both occupational and non-occupational exposures and for adults and children.
The new recommendations provide simpler regimens using ARVs already being used
in treatment. The implementation of the new guidelines will enable easier
prescribing, better adherence and increased completion rates of PEP to prevent
HIV in people who have been accidentally exposed to HIV such as health workers
or through unprotected sexual exposures or sexual assault.
5. Harm reduction
for injecting drug users
People who inject drugs can take precautions against becoming infected
with HIV by using sterile injecting equipment, including needles and syringes,
for each injection. A comprehensive package of interventions for HIV prevention
and treatment includes:
·
needle and syringe programmes;
·
opioid substitution therapy for people dependent on opioids and other
evidence based drug dependence treatment;
·
HIV testing and counselling;
·
HIV treatment and care;
·
access to condoms; and
·
Management of STIs, tuberculosis and viral hepatitis.
6. Elimination of
mother-to-child transmission of HIV (EMTCT)
The transmission of HIV from an HIV-positive mother to her child during
pregnancy, labour, delivery or breastfeeding is called vertical or
mother-to-child transmission (MTCT). In the absence of any interventions during
these stages, rates of HIV transmission from mother-to-child can be between
15-45%. MTCT can be nearly fully prevented if both the mother and the child are
provided with ARV drugs throughout the stages when infection could occur.
WHO recommends options for prevention of MTCT (PMTCT), which includes
providing ARVs to mothers and infants during pregnancy, labour and the
post-natal period, and offering life-long treatment to HIV-positive pregnant
women regardless of their CD4 count.
In 2014, 73% [68–79%] of the estimated 1.5 [1.3-1.6] million pregnant
women living with HIV globally received effective antiretroviral drugs to avoid
transmission to their children.
Treatment
HIV can be suppressed by combination ART consisting of 3 or more ARV
drugs. ART does not cure HIV infection but controls viral replication within a
person's body and allows an individual's immune system to strengthen and regain
the capacity to fight off infections.
In 2015, WHO released a new "Guideline on when to start
antiretroviral therapy and on pre-exposure prophylaxis for HIV.” The guidelines
recommend that anyone infected with HIV should begin antiretroviral treatment
as soon after diagnosis as possible.
By mid-2015, 15.8 million people living with HIV were receiving ART
globally. By end of 2014, 40% [37–45%] of all people living with HIV were on
ART.
Based on WHO’s new recommendations, to treat all people living with HIV
and offer antiretrovirals as an additional prevention choice for people at
"substantial" risk, the number of people eligible for antiretroviral
treatment increases from 28 million to all 37 million people. Expanding access
to treatment is at the heart of a new set of targets for 2020 which aim to end
the AIDS epidemic by 2030.
Source
1. WHO