While World Health Organistion guidelines propose simplified approaches to antiretroviral treatment (ART) for HIV, they do not recommend a ‘one size fits all’ approach.
Treatment programmes need to respond to the different needs of children and adolescents, of people with co-infections in addition to HIV, and of marginalised key affected populations.
. All human beings, rich and poor, strong and weak, male and female, of all races and religions, are to be treated equally and with respect.
While young people may have less autonomy than adults, the right of the child to health and the obligation of institutions to act in the best interests of the child are enshrined in human rights treaties.
However, stigmatising attitudes towards people living with HIV and towards groups that are more at risk of HIV can result in health services failing to respond adequately to their needs. Healthcare providers sometimes treat patients with dismissive or discriminatory attitudes or behaviour, for example neglecting patients, breaching confidentiality, verbally abusing patients or denying care.
Same-sex behaviour is criminalised in 78 countries, with anxiety about mistreatment often disrupting individuals’ access to healthcare. Many more countries criminalise sex work and the use of drugs, creating barriers for people with these behaviours to have trusting relationships with healthcare providers. Similarly, prosecutions for HIV non-disclosure, exposure and transmission have been recorded in at least 49 countries and may curtail open discussion with healthcare staff.
Evidence from the People Living with HIV Stigma Index demonstrates the impact of stigma and discrimination on the health of people living with HIV. One in eight respondents living with HIV reported being denied health services and one in five reported experiencing physical assault because of their HIV status.
Treating children
It is vital that infants and young children who are living with HIV receive HIV treatment as they are at an elevated risk of poor treatment outcomes - without treatment, half will die by their second birthday. Given the strong evidence of benefit, WHO recommends treatment for all children and prioritises it for the youngest infants and those with compromised immune function.
Despite this, children are less likely than adults to receive treatment: only 32% were receiving treatment in 2014 in comparison to 41% of adults.
Retention in care is frequently a problem in many countries, but thanks to robust systems for tracking patients and because healthcare is provided free of charge, China is an example of a country that has made great efforts to retain children in care.
Low rates of HIV testing in infants prevent those who need it getting prompt access to HIV treatment. Diagnosing and retaining children in care presents unique challenges because of their dependence on parents and caregivers. The limited range of antiretroviral drugs which are available in paediatric formulations – especially second- or third-line alternatives – makes treatment more challenging, especially given the potential difficulty of adherence to medication which may have an unpleasant taste and is associated with a stigmatised health condition.
Treating adolescents
Young people who have been living with HIV since birth, can face challenges in the transition from paediatric treatment services—where parents and guardians have primary responsibility for their care—to adult treatment services, where they will need to take much greater responsibility for their own care. As with any other long-term health condition, the transition to adult services should be carefully managed with full involvement of the young person as abrupt changes can be confusing and destabilising.
A failure to follow good practice in this area has resulted in poor rates of retention in care and low coverage of HIV treatment among adolescents. Adolescent-specific services are rarely available and healthcare providers may have little experience of providing services for young people. They may not understand the needs of adolescents living with HIV and may have judgemental attitudes towards those who are sexually active. Adherence may be challenging for adolescents due to unstable lives that are not conducive to daily medication and not being fully involved in treatment decision-making.
A study of 160 HIV clinics in Kenya, Mozambique, Rwanda and Tanzania found that young people aged 15 to 24 years were more likely to drop out of care, both before and after beginning HIV treatment, than other age groups. Young men were especially likely to drop out of care. However, drop out was considerably lower for adolescents who attended clinics that provided sexual and reproductive health services (including condoms) or provided adolescent support groups.
For adolescents who were not diagnosed in childhood and who may have acquired HIV during adolescence, laws and policies on the age of consent for HIV testing prevent many adolescents from knowing their HIV status and therefore accessing HIV treatment. Late diagnosis of HIV is a particular issue for adolescents who also belong other other key populations (for example, they inject drugs), as they are often reluctant to seek services because of stigma and discrimination.
Treating key affected population
Just as punitive laws, human rights abuses and stigma increase the vulnerability of key populations (such as people who inject drugs and transgender people) to HIV, they also act as barriers to key populations accessing HIV treatment. Accurate statistics comparing treatment access in different populations are rarely available but when they are, they frequently show limited uptake.
For example, transgender people often face stigma and ill treatment in healthcare settings, including refusal of care, verbal abuse and violence.Men who have sex with men living in low- and middle-income countries generally report low access to ART, with especially low rates in countries which criminalise same-sex behaviour and in men who feel they are subject to social stigma.
Services which are culturally and clinically sensitive to the specific needs of key populations can improve access. Peer-based interventions and multidisciplinary teams providing non-judgemental care show promise. Providing HIV treatment, hepatitis treatment and opioid substitution therapyat the same site can improve the engagement of people who inject drugs. Services for transgender people should consider the adverse interactions between antiretroviral treatment for HIV and hormone therapy.
The World Health Organisation has produced comprehensive guidance on HIV services for key populations.
Treating people with co-infections
Due either to untreated HIV’s suppression of the immune system or to overlapping risk behaviours, many people are living with both HIV and another infection. These additional infections are known as co-infections.
Globally, 1.2 million of the 9.6 million people who fell ill with tuberculosis (TB) in 2014 also had HIV. The burden of HIV/TB co-infection is heaviest in Africa, where 74% of people with an HIV/TB co-infection live.Moreover one third of people living with HIV who died in 2015 in fact died of tuberculosis (which is an AIDS-defining illness).Two other co-infections, malaria and cryptococcal meningitis, also cause significant illness and death in people living with HIV in Africa.
Chronic hepatitis B affects 5% to 20% of people living with HIV worldwide, and hepatitis C affects 5% to15% - but up to 90% among people with HIV who inject drugs. Liver disease caused by viral hepatitis is a major cause of death in people living with HIV in Eastern Europe.
However, health services do not always work in integrated ways and may even fail to provide screening for common co-infections. Although significant progress has been made in the past decade, only half of tuberculosis patients were tested for HIV in 2014. Equally, HIV-positive patients need to be screened for TB symptoms and viral hepatitis, especially in those regions and populations where the infections are prevalent.
Treatments for co-infections should generally be provided at the same time as treatment for HIV and the care carefully co-ordinated – for example the possibility of drug interactions needs to be managed. By strengthening the immune system, ART contributes to the management of co-infections.
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