Speech of Dr Luis Gomes Sambo, Regional Director of WHO at the opening ceremony of the International Conference on AIDS and other Sexually Transmitted Infections in Africa – ICASA

Submitted by dinara on Mon, 17/07/2017 - 16:28

Cape Town, South Africa, 7th December 2013
WHO’s New HIV Treatment and Prevention Guidelines – What they Mean for Africa

  • Your Excellency the Vice President of South Africa, Mr. Kgalema Motlanthe,
  • Her Excellency the First Lady of the Republic of Zambia, Dr. Christine Kaseba Sata,
  • The Executive Director of UNAIDS, Mr. Michel Sidibe
  • The President of the Society for AIDS in Africa,
  • Excellences, Ladies and Gentlemen,
  • Distinguished Guests and Participants,
  • All protocols observed.

Let me start by paying a special tribute to President Nelson Mandela, a great leader and Statesman who advocated tirelessly to eliminate discrimination against people living with HIV/AIDS. He will remain a Pan-African icon and a source of inspiration to all of us. May His Soul rest in peace.

Distinguished ladies and gentlemen, I am honored to have been invited to speak to you during the Opening Ceremony of the 17th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA).  Every two years ICASA offers us an opportunity to reflect on where we have come from and where we are going in relation to the HIV/AIDS epidemic/pandemic. The Conference also helps to mobilize African leaders, partners and the community at large to increase ownership, commitment and support to the AIDS response. We therefore need to continue supporting the organization of this important forum.

Sub-Saharan Africa continues to be the region most affected by HIV/AIDS. According to UNAIDS/WHO estimates, in 2012, we accounted for 1.6 million (70%) of the 2.3 million new HIV infections in the world. Sub-Saharan Africa accounted for 1.2 million (75%) of the 1.6 million HIV-related deaths in the world. 

•    Excellences, Distinguished Guests and Participants

This evening, I will focus my speech on the “World Health Organization’s New HIV Treatment and Prevention Guidelines and What they Mean for Africa.”

In recent years, antiretroviral therapy (ART) in most countries has followed the treatment eligibility criteria issued by WHO in 2010, that recommended treatment for every person that tests HIV-positive and has CD4 cell counts of ≤350 cells/mm3 or who are co-infected with active Tuberculosis or Hepatitis B.  Since then, there has been increasing scientific evidence of the benefits to individuals and populations of early initiation of antiretroviral therapy (ART). This evidence has demonstrated that starting ART at a CD4 cell count of ≤500 cells/mm³ compared with ≤350 cells/mm³, has the potential to reduce HIV-related morbidity, mortality and onward transmission of the virus.

•    Excellences, Distinguished Guests and Participants

In addition to the benefits of early initiation of ART, safer, simpler, efficacious and affordable new ARV regimens are now available. Furthermore, newer testing and monitoring technologies and approaches for earlier diagnosis and patient follow-up are available.There is also increasing awareness of the adverse association between HIV infection and other health conditions such as tuberculosis, malaria, viral hepatitis, and some non-communicable diseases.

In response to these developments, WHO, in June 2013, published new recommendations on the use of antiretroviral (ARV) medicines in a document entitled — “Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection; Recommendations for a Public Health Approach.”  These guidelines aim to consolidate existing and new guidance from different sources into one document that covers all aspects of the use of ARV medicines for HIV treatment and prevention in different populations, age groups and settings. The new guidelines promote earlier initiation of ART, further simplification of ARV regimens, with a single preferred first line regimen, available as “a one pill a day fixed-dose combination,” for adults, pregnant women, adolescents and older children. They also promote improved monitoring of people on ART. The guidelines also recommend immediate ART for all HIV-infected children below five years of age and HIV-infected pregnant and breastfeeding women.

Furthermore, the guidelines provide advice on how to improve the efficiency and effectiveness of HIV/AIDS programs and related services.

•    Excellences, Distinguished Guests and Participants

Widening access to ART in recent years has reversed the trend of the HIV pandemic.  HIV-related mortality rates are declining, even in very high burden countries. It is estimated that, by implementing the new WHO Consolidated Guidelines, an additional three million deaths would be averted globally by 2025 compared with the use of the previous guidelines. This figure translates into an additional 39% reduction in HIV-related deaths. In addition, implementing the new guidelines could prevent up to 3.5 million new HIV infections by 2025. This would, in turn, contribute to a reduction in the number of persons eligible for ART in the long term.

High HIV prevalence has hampered TB control in countries since it increases the risk of progression to active tuberculosis.  Available data from low- and middle-income countries show that ART can reduce the risk of TB by up to 65%.  Therefore, implementing the new guidelines may also contribute to reducing the burden of tuberculosis.

•    Excellences, Distinguished Guests and Participants

The implementation of the WHO 2013 guidelines will have implications for health care delivery systems in Africa.  Based on the current status of the epidemic, the total number of individuals eligible for ART is estimated to increase by 53% from 12.4 million to 19 million. This increase will require further investments in health systems infrastructure in order to accommodate the additional number of people under ART. An increasing number of health workers will be required to deliver ART despite the human resources for health crisis in Africa. In addition, laboratory capacity needs to be strengthened at all levels of national health services in order to ensure HIV diagnosis and viral load testing for treatment monitoring. Moreover, we will need more effective capacity in health logistics, particularly in terms of procurement and the supply chain of medicines and commodities, in order to prevent interruption of treatment. Furthermore, health information systems and statistical services should be upgraded and respond to the needs for HIV surveillance, pharmacovigilance, and monitoring and evaluation of national HIV/AIDs programs. 

2012 estimates show that the annual cost of treating an HIV infected person using ARVs ranges from US$ 120 to US$ 200. Although the contributions of national governments towards HIV treatment and care has increased in recent years, dependence on external funding remains a matter of great concern. It is estimated that 60% of ART costs are covered from international sources. In addition the annual USD 10 to 12 billion that is currently required to cover the comprehensive response to HIV in the African Region, there will be need to mobilize a further USD 1 billion every year to assist the additional number of persons.

There are several questions that we need to ask ourselves? For instance, can national governments and health systems deliver on the new guidelines? Can we meet the current and additional costs of introducing the new guidelines at the current levels of domestic and international funding for HIV/AIDS?

•    Excellences, Distinguished Guests and Participants

More than half of the people living with HIV in the African Region do not know their HIV status. Among those who do know their HIV status, frequently they were tested late. Evidence shows that many people start treatment when they are already significantly immune-compromised, resulting in poor treatment outcomes and continuing HIV transmission. A meta-analysis from studies conducted in sub-Saharan Africa indicates that 25% of people who test positive for HIV actually initiate ART. I should also state that there are high rates of drop-out along the treatment cascade, from diagnosis of HIV to retention in HIV care and treatment. This problem of patients dropping out of ART needs to be seriously addressed if we want to achieve the maximum benefits of earlier treatment.

•    Excellences, Distinguished Guests and Participants

The 2011 United Nations Political Declaration on HIV/AIDS committed the world to put 15 million persons living with HIV/AIDS on ART by 2015.  Concerning treatment scale-up trends of the past ten years, and using the 80% universal access target, we can group the 47 African region countries as follows: The first group relates to the 15 countries where there has been significant progress towards the target of 80%. These achievements were made through strong political commitment, robust funding from domestic and external sources, adequate planning, adherence to technical norms, decentralized delivery, targeting specific groups who need ART, and meaningfully involving community structures and networks. The second group relates to the 9 countries where the 80% coverage target in 2015 is within reach, but only with greater  efforts. The third group comprises 23 countries, which are behind and would require immense efforts to reach the universal access target of 80% ART coverage. None of these countries is likely to reach the target in 2015 under the current pace.  Diverse factors are holding them back – such as political instability, poor health infrastructure and persistent stigma and discrimination. 

•    Excellences, Distinguished Guests and Participants

Let me end by reiterating that, to maximize the multiple benefits of earlier initiation of ART as articulated in the new WHO ARV guidelines, - Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a Public Health Approach - people should adhere to testing and counselling and be offered appropriate treatment and care.

Towards this end, African Ministers of Health during the Sixty-third session of the WHO Regional Committee in September 2013 adopted a Resolution (AFR/RC63/R7 “The 2013 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for treating and preventing HIV Infections; Recommendations for a Public Health Approach- Implications for the African Region”), which urges countries to  adapt national ART guidelines and related service delivery tools to the new WHO consolidated guidelines according to the specific context of each country. The Resolution also calls on the World Health Organization and partners to advocate for additional funding and to provide harmonized support to countries for the HIV/AIDS response.

On behalf of the World Health Organization, I would like to call upon Heads of State and Governments in Africa to continue to provide the required leadership for the national HIV/AIDS response in their respective countries and ensure that the national multi-sectoral coordinating committees for HIV/AIDS are fully functional.

We would also like to call on African Governments to continue creating an enabling environment for the fight against HIV/AIDS. It is their responsibility to provide governance and forge appropriate domestic and external partnerships to mobilize, allocate and efficiently use the domestic and external resources that are devoted to fight HIV/AIDS. Ministers of Health are expected to continue to provide leadership in the health systems response to achieve the goals of health care coverage and reduction of the HIV burden. More attention needs to be paid to addressing the needs of key populations at risk of HIV infection by creating an enabling environment for inclusiveness and universal access.

We recall the principles of international solidarity and partnerships and urge all stakeholders to sustain and increase their support for the fight against HIV/AIDS in Africa where the levels of both incidence and prevalence are still unacceptably high.

We appreciate the recent scientific breakthroughs in HIV/AIDs research and congratulate the research community on their achievements. We still have questions to answer, and therefore both biomedical and operations research should continue to bring new knowledge to address the intractable challenges hampering the effective control of HIV/AIDs.

We also call upon the private sector to continue their needed support to national HIV/AIDS programmes.

We urge Civil Society to continue playing their critical role in advocacy and in ensuring access and equity in the response to HIV/AIDS.

We encourage Persons Living with HIV/AIDS to maximize the benefits of ARV therapy through continued adherence to medications and retention in long-term care.

We also encourage any individual who does not know his or her HIV status to go and get tested. 

And let all of us as individuals, both infected and not infected, hold ourselves collectively accountable in the fight against HIV/AIDS.

I want to take this opportunity to remind that primary prevention through the ABC approach of “abstinence, be faithful, and use a condom” is still the most simple and affordable way of preventing HIV infection.

•    Excellences, Distinguished Guests and Participants

I would like to give a few words of thanks to the Society for AIDS in Africa for holding the 17th ICASA. I express my appreciation to the Government and people of South Africa for hosting this Conference in the beautiful city of Cape Town.

I reiterate the commitment of the World Health Organization to continue to provide technical leadership and normative guidance in support to African Governments and complementing the important roles of other international agencies such as UNAIDS, the Global Fund, bilateral agencies, the private sector, Civil Society Organizations and Non-State Actors.

As we participate in this 17th ICASA, let us all resolve to do more to fight this deadly scourge of our times.  We are making progress but we still need to do more.

I thank you very much for your attention, and I wish you all a very successful Conference.