A man wearing a hard hat and reflective vest presenting a case of medicine.

Approaching 95-95-95 HIV/AIDS Goals by Focusing on Patients .

November 30, 2020

Ensuring adherence to HIV treatment can significantly improve the quality of life for people living with HIV. A patient-centric treatment approach is successfully reducing the burden and helping the global health community maintain the progress made to end AIDS by 2030 during COVID-19.

Going to a health care facility to pick up antiretrovirals (ARVs) became a precarious task for the approximately 38 million people across the globe living with HIV during COVID-19. The risk of exposure while accessing essential services and counseling suddenly became too high for immunocompromised patients. As the situation unfolded, the global health community grappled with a difficult dilemma —protecting health workers and patients from exposure while ensuring continuity of services for people living with HIV (PLHIV).

Ensuring continuous access to treatment and services is critical to staying on track to achieve UNAIDS 95-95-95 goals by 2030. To fast-track the progress made, 95 percent of PLHIV who know their status need to be on ARV treatment. The global health community, including the USAID Global Health and Supply Chain Program–Procurement and Supply Management (GHSC-PSM) project, is acting quickly to make sure that this progress is not lost to the global disruptions that the pandemic has generated. One key solution is protecting health workers and immunocompromised patients with differentiated service delivery. This delivery method focuses on clients to simplify and adapt HIV services to serve PLHIV while reducing unnecessary burdens on the health system.

Epidemics don’t stop being lethal during pandemics

Adapting to COVID-19 has been a major challenge for PLHIV, who require continuous access to therapy and services to stay healthy. Before COVID-19, it was already challenging for many people in rural areas to access care at the nearest health center because of poor road infrastructure, overburdened health posts, internal conflict, natural disasters, and the lack of last-mile services. In Namibia where HIV/AIDS is the leading cause of death, and more than 200,000 PLHIV need constant access to medication, 84 percent of the country roads are unpaved, making it difficult to reach the closest pharmacy or health center even before COVID-19. Continuity of services during the pandemic is critical, which is why the U.S. President’s Emergency Plan for AIDS Relief has focused on expanding multimonth dispensing (MMD) of ARV to PLHIV.

MMD reduces the PLHIV risk of exposure by providing an increased supply of drugs, from 30-tablet bottles to 90- or 180-count bottles. So, instead of picking up a monthly supply, PLHIV can obtain a three-to six-month supply, decreasing their travel. Fewer trips to the pharmacy also means decongestion at the health facility and less exposure for patients and health care providers, ensuring social distancing and preventing COVID-19. By the end of 2020, GHSC-PSM had delivered 13.9 million 90-count bottles and more than 200,000 180-count bottles of tenofovir, lamivudine, and dolutegravir (TLD) to 20 countries over the life of the project.

12,720

90-count bottles of TLD delivered in Namibia

27,073

90-count bottles of TLD delivered in Botswana

2,759,865

90-count bottles of TLD delivered n Zambia

Eleven-year-old Helvi Isangu collects her ARV medication at the Rundu State Hospital, Kavango East Region, Namibia. Photo: Salome Nzuma/GHSC-PSM.

For example, GHSC-PSM in Namibia coordinated with the government early to ensure there was a sufficient supply of first-line ARVs to meet patient demand throughout the lockdown. GHSC-PSM’s MMD scale-up in Namibia has likely saved 25,440 trips to the pharmacy, protecting patients and health workers by reducing their exposure.The project also was easing the burden of PLHIV with MMD even before the pandemic. Eleven-year-old Helvi Isangu used to walk about an hour each way to the Rundu State Hospital in Kavango East Region to collect ARVs. She and her aunt would wait patiently in line at the hospital, which sees an average of 160 patients a day. With MMD’s wide implementation in Namibia’s health facilities, missed school days, traveling to the hospital, and spending hours in line to collect medication will be a thing of the past for PLHIV like Helvi.

What we have achieved so far

Before the pandemic, the global health community had made great progress to end AIDS. Between 2008 and 2017, there was a 43 percent reduction in AIDS-related deaths, and the number of PLHIV on treatment also increased, reaching 21.7 million of 36.9 million. With funding from U.S. President’s Emergency Plan for AIDS Relief, GHSC-PSM supports HIV prevention, testing, and treatment, as well as suppression of viral load through data-focused and sustainable supply chain and health system strengthening activities.

GHSC-PSM’s treatment approach focuses on patients’ needs by simplifying treatment to ensure adherence, improving the quality of life for PLHIV, and contributing to 95-95-95 goals to end AIDS. TLD is the preferred first-line ARV. Using TLD for HIV treatment is easier, safer, and more effective for tens of millions of people. Since 2017, when the treatment was developed and widely accepted as preferred, GHSC-PSM has worked to scale-up its transition by delivering 41.7 million bottles of TLD to 23 countries, providing 5.8 million patient-years of HIV treatment over the life of the project. TLD transition has been key to several countries’ reaching HIV/AIDS fast-track targets.

With support from GHSC-PSM, Botswana became one of the first countries to transition to TLD in 2018. The project completed the transition in two phases, overcoming patients’ long wait times while clinicians reviewed and changed prescriptions, fighting misconceptions, and working with patients who wanted to adhere to their previous treatment. Even with these challenges, however, the project’s work with the Ministry of Health and Wellness and clinical implementing partners was key to the transition. TLD is the preferred first-line ARV for treating HIV because it is just one daily pill that is highly effective, safe, and proven to rapidly suppress viral load in adult and adolescent patients with HIV.

Harrison Nzima happily holds his antiretroviral treatment, TLD. Photo credit: GHSC-PSM

In Zambia, GHSC-PSM also helped develop a robust and thoughtful transition strategy to TLD. Harrison Nzima was one of the estimated 1.2 million PLHIV in Zambia who benefitted from switching to TLD. He notes during his hospital visits that TLD is readily available. He has not experienced any side effects, and he is happy with his progress. Now, with improved health, he is ready to work again to earn a living. Harrison is an example of restored hope and a restored quality of life, thanks to the critical commodities that were made available by the global health supply chain.

"People out there should take the medicine
like I am and live long!”

Harrison Nzima

The next generation of care

Although considerable progress has been made, there is still a long way to go for pediatric treatment of HIV. Of the 1.8 million children aged 0 to 14 living with HIV globally, only 53 percent were receiving life-saving ARVs in 2019, and 88 percent of them live in sub-Saharan Africa. With the absence of ARVs, 50 percent of children living with HIV die before their second birthday, and 80 percent die before their fifth. Early initiation of treatment significantly lowers mortality among children, but fewer than half were receiving treatment in 2014.

Pediatric ARV transition to dolutegravir 10mg is the next step toward the 95-95-95 goals and ending AIDS by 2030. If the global health community sticks to fast-tracking, 5.9 million infections among children will be averted by 2030. Children like Helvi can live a healthy life if they adhere to treatment, which is why making it easier and safer for them to receive and take their medication is vital.

“Helvi is an orphan and has been living with HIV since she was born,” said Mpareko Kasova, Helvi’s aunt. “She lost both her parents to AIDS, and she has been living under my care, but it wasn’t until 2016 that her HIV status became known to her.” GHSC-PSM works tirelessly to ensure that a resilient, adaptable, and sustainable HIV/AIDS global supply chain reaches Helvi and 1.8 million children living with HIV, and that these children have continuous access to the latest advances in pediatric HIV treatment for the foreseeable future.