Date Published: November 7, 2017
Publisher: Public Library of Science
Author(s): Wafaa M. El-Sadr, Katherine Harripersaud, Miriam Rabkin
Abstract: In a Perspective, Wafaa El-Sadr and colleagues discuss tailored approaches to treatment and prevention of HIV infection.
Partial Text: A decade ago, today’s progress towards confronting the global HIV epidemic would have been unimaginable. A remarkable global mobilization of resources through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis and Malaria, combined with the commitment of affected countries and communities, has enabled 19.5 million persons living with HIV (PLHIV) to access life-saving antiretroviral therapy (ART) . This has resulted in decreasing HIV-related morbidity and mortality and contributed to a significant decline in the number of new infections .
Differentiated care may be an important step towards addressing health system and individual barriers to achieve HIV treatment goals . Whereas earlier efforts, anchored in the public health approach, often distinguished only 2 groups of adult patients—pregnant and nonpregnant—differentiated care models tailor service frequency, service location, service intensity, and type of service provider for more categories of PLHIV . The goal of differentiated care is to provide client-centered services that encourage engagement, adherence, and retention in care while also maximizing efficiency.
Achieving epidemic control is also critically dependent on HIV prevention. Primary prevention of HIV acquisition is required in addition to optimizing the potential of HIV treatment as a prevention tool . Between 21% and 96% of new HIV infections occur among key populations and their sexual partners , and the enormous structural and societal barriers described above affect access to prevention services as well as treatment. Interventions to engage key populations have been shown to alleviate some of these impediments. For example, a study conducted in Kenya showed that the use of sex worker peer educators led to an increase in safer sexual behaviors and noted that individuals who participated in more peer education sessions achieved higher levels of protection . Another study, also conducted in Kenya, demonstrated the feasibility of training health workers to better understand the needs of men who have sex with men . Despite these successes, novel and effective strategies remain urgently needed to decrease HIV incidence amongst key and priority populations, and engaging members of these communities in designing and testing primary prevention initiatives is a priority.
As the expression goes, “What got us here won’t get us there.” Attaining epidemic control will require continued rapid expansion of the number of PLHIV on treatment, engaging populations at risk for HIV infection, improvement of the quality of HIV services, and new approaches to program design and implementation (Fig 1). The scale-up of differentiated care has the potential to relieve crowded health facilities and overworked providers by moving stable patients on ART to more patient-centered models, enhancing both efficiency and quality. Differentiated care can also facilitate the engagement of other groups of PLHIV in models of service provision that meet their specific clinical and psychosocial needs. At the same time, innovations are urgently needed in the development of differentiated prevention delivery models that address the needs of specific groups at substantial risk for HIV infection. In addition, it is now more important than ever to utilize population-based, programmatic, and research data in shaping programs and prioritizing populations . For instance, disaggregation of seemingly favorable national population HIV data by sex and age shows important gaps in the HIV care and HIV prevention continua for men and youth living with HIV.