To address constraints on capacity and human resources and to improve retention over time, Médecins Sans Frontières and the authorities of Tete Province in Mozambique launched in 2008 an innovative out-of-clinic model of antiretroviral therapy distribution and adherence monitoring by community antiretroviral therapy groups.
In this model, people receiving antiretroviral therapy who were stable for six months were invited to form groups. Each month a group meeting was held in the community before each clinic visit and the designated group leader counted each member’s pills (adherence check). Any new signs or symptoms, adherence problems or intention to relocate to another area or interrupt treatment were discussed and documented for each person on the group-held group monitoring form. Individual appointment cards were given to the group representative so that they could be taken to the health facility to be completed. At the facility level, the group monitoring form was jointly reviewed and the group representative discussed each group member with a counsellor or clinician. Antiretroviral therapy and prophylactic drugs for each group member were then given to the group representative, to be eventually distributed upon return to the community.
Between February 2008 and May 2010, 1384 people living with HIV were enrolled in 291 groups, with an average of 4.75 people per group.
The median follow-up time within a group was 12.9 months. Early outcomes have been satisfactory in terms of mortality and retention in care, showing the feasibility of out-of-clinic approaches. During this time, 83 (6%) people were transferred out, and of the 1301 people still in community groups, 1269 (97.5%) remained in care, 30 (2.3%) died, and 2 (0.2%) were lost to follow-up. Moreover, in terms of workload reduction, staff members at health facilities reported that community antiretroviral therapy groups resulted in an approximately four-fold reduction in consultations among the people receiving care based on a community antiretroviral therapy group.
Beyond considerably reducing the transport and opportunity costs associated with antiretroviral therapy uptake, the community antiretroviral therapy group model encourages people to take greater responsibility for their own health by engaging them as active partners in health care delivery and promotes the development and reinforcement of social networks and peer support, which have been identifi ed as important ways to support treatment adherence.
Source: Decroo et al. (43).
Table 5.3 Number of adults and children (combined) receiving and eligible for antiretroviral therapy, and estimated percentage
coverage in low- and middle-income countries by region, December 2009 to December 2010
a,b,cGeographical region
Estimated number of people eligible for antiretroviral
Estimated number of people eligible for antiretroviral
Sub-Saharan Africa 5 064 000 10 400 000
[9 700 000–11 000 000]
49%
[46–52%] 3 911 000 9 600 000
[9 000 000–10 200 000]
41%
Africa 842 000 2 800 000
[2 600 000–3 100 000]
Latin America and the
Caribbean 521 000 820 000
[710 000–920 000]
63%
[57–73%] 469 000 780 000
[670 000–870 000]
60%
[54–70%]
Latin America 461 000 720 000
[620 000–810 000]
64%
[57–74%] 416 000 690 000
[590 000–780 000]
60%
[53–70%]
Caribbean 60 300 100 000
[91 000–110 000]
Europe and Central Asia 129 000 570 000 [500 000–650 000]
23%
[20–26%] 114 500 520 000
[450 000–600 000]
22%
[19–25%]
North Africa and the
Middle East 14 900 150 000
[120 000–190 000]
[13 400 000–15 000 000]
47%
[44–50%] 5 255 000 13 300 000
[12 400 000–14 100 000] 39% [37–42%]
Note: some numbers do not add up because of rounding.
a See Box 5.9 for further information on the methods for estimating the need for and coverage of antiretroviral therapy in 2010.
b The 2009 fi gures may differ from those previously published because countries have submitted newly available data.
c All estimated needs have been developed according to 2010 WHO guidelines and criteria for initiating treatment.
d The coverage estimate is based on the unrounded estimated numbers of people receiving and needing antiretroviral therapy.
As the region most affected by the epidemic, sub-Saharan Africa recorded the greatest increase in the absolute number of people receiving treatment in 2010, from 3 911 000 in December 2009 to about 5 064 000 a year later – a 30% increase. In all other regions, growth rates were lower than 25% from 2009 to 2010.
Latin America is the region with the smallest percentage increase in the number of people receiving antiretroviral
therapy in 2010 versus 2009: 11%. Although this may be partly explained by the fact that most large countries in the region have already achieved relatively high levels of coverage, it may also be related to diffi culty in scaling up HIV testing and counselling and effectively diagnosing HIV infection in early stages (44).
Twenty countries accounted for 84% of the people receiving antiretroviral therapy in low- and
middle-7
Fig. 5.3 Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 2002–2010
z North Africa and the Middle East
z Europe and Central Asia
z East, South and South-East Asia
z Latin America and the Caribbean
z Sub-Saharan Africa
End
income countries in 2010, most in sub-Saharan Africa (Table 5.4). Home to the greatest absolute number of people living with HIV, South Africa now provides antiretroviral therapy to a fifth of all the people receiving antiretroviral therapy in low- and middle-income countries. Zimbabwe recorded the highest rise in enrolment, with an increase of almost 50% in the number of people receiving treatment between December 2009 and December 2010. Despite continued progress, however, treatment in many of these countries remained well below the estimated needs.
At least 745 000 people are receiving antiretroviral therapy in high-income countries, including about 430 000 in Europe, 300 000 in North America and the Caribbean, and 16 700 in Asia, Oceania and the Middle East. At the end of 2010, the total number of people accessing antiretroviral therapy worldwide, including in high-income countries, was estimated to be about 7.4 million.
The Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States President’s Emergency Plan
for AIDS Relief remained the two major international sources of funding for antiretroviral therapy programmes in low- and middle-income countries in 2010. As of December 2010, Global Fund–supported programmes provided treatment to 3.0 million people, and programmes funded by the United States President’s Emergency Plan for AIDS Relief supported antiretroviral therapy for 3.2 million people. About 1.5 million people were receiving treatment through programmes jointly funded by the two initiatives; hence, together they supported programmes that provided treatment to about 4.7 million people at the end of 2010 (45,46).
Coverage of antiretroviral therapy in low-and middle-income countries continued to increase in 2010 and reached 47% [44–50%] of the 14.2 million [13 400 000–15 000 000] people estimated to need it at the end of 2010 (Table 5.3).
As in previous years, Latin America and the Caribbean had the highest regional coverage level in 2010, at 63%
[57–73%], because of the relatively longer duration
Table 5.4 Twenty low- and middle-income countries with the highest number of people receiving antiretroviral therapy and
their respective share of the total number of people receiving antiretroviral therapy in low- and middle-income countries as of December 2010
South Africa 971 556 1 389 865 55% [52–58%] 43% 21%
Kenya 336 980 432 621 61% [56–66%] 28% 7%
India 330 300 424 802 ... [30–38%]a 29% 6%
Nigeria 302 973 359 181 26% [24–28%] 19% 5%
Zambia 283 863 344 407 72% [67–77%] 21% 5%
Zimbabwe 218 589 326 241 59% [54–62%] 49% 5%
United Republic of Tanzania 199 413 258 069 42% [39–46%] 29% 4%
Malawi 198 846 250 987 ... [49–57%]a 26% 4%
Uganda 200 413 248 222 47% [43–51%] 24% 4%
Thailand 216 118 236 808 67% [55–85%] 10% 4%
Ethiopia 176 632 222 723 ...a 26% 3%
Mozambique 170 198 218 991 40% [36–46%] 29% 3%
Brazil 185 982 201 279 70% [65–75%] 8% 3%
Botswana 145 190 161 219 93% [89–>95%] 11% 2%
Rwanda 76 726 91 984 88% [76–>95%] 20% 1%
Cameroon 76 228 89 455 38% [34–43%] 17% 1%
Namibia 70 498 88 717 90% [78–>95%] 26% 1%
China 65 481 86 122 32% [26–37%] 32% 1%
Russian Federation 75 900 79 430 ... [21–29%]a 5% 1%
Lesotho 61 736 76 487 57% [53–60%] 24% 1%
a Estimates of the number of people needing antiretroviral therapy are currently being revised and will be adjusted, as appropriate, based on ongoing data collection and analysis. Therefore,
of antiretroviral therapy programmes in some of the region’s largest countries.
In sub-Saharan Africa, antiretroviral therapy coverage reached 49% [46–52%] in 2010. The region accounted for 73% of the estimated treatment need in low- and middle-income countries and 76% of the total number of people receiving treatment at the end of 2010. However, important intraregional differences in coverage were observed: whereas 56% [53–59%]
of the people who needed antiretroviral therapy in eastern and southern Africa had access, in western and central Africa antiretroviral therapy coverage was only 30% [28–33%].
Coverage in 2010 improved across all other regions as well, but was lowest in East, South and South-East Asia, with 39% [36–44%], Europe and Central Asia, with 23% [20–26%] and North Africa and the Middle East, where only 10% [8–13%] of the regional antiretroviral
therapy needs were met. In these regions, many countries face HIV epidemics that are concentrated among key populations at higher risk for HIV infection, who often have relatively greater diffi culty in accessing treatment and care services (section 6.4).
At the end of 2010, ten low- and middle-income countries, including three countries with generalized epidemics (Botswana, Namibia and Rwanda), four countries with concentrated epidemics (Cambodia, Chile, Guyana and Nicaragua) and three countries with low level epidemics (Croatia, Cuba and Slovakia), had already achieved universal access to antiretroviral therapy, commonly understood as providing antiretroviral therapy to at least 80% of the people who need it (Table 5.6). Seven countries (Argentina, Brazil, Dominican Republic, Mexico, Swaziland, Uruguay and Zambia) had near-universal coverage levels, between 70% and 79%, and 31 additional countries had coverage rates higher than 50%.
Box 5.9