Beyond viral suppression of HIV – the new quality of life frontier


Background:
In 2016, the World Health Organization (WHO) adopted a new Global Health Sector Strategy on HIV for 2016–2021. It establishes 15 ambitious targets, including the ‘90-90-90’ target calling on health systems to reduce under-diagnosis of HIV, treat a greater number of those diagnosed, and ensure that those being treated achieve viral suppression.

Discussion:
The WHO strategy calls for person-centered chronic care for people living with HIV (PLHIV), implicitly acknowledging that viral suppression is not the ultimate goal of treatment. However, it stops short of providing an explicit target for health-related quality of life. It thus fails to take into account the needs of PLHIV who have achieved viral suppression but still must contend with other intense challenges such as serious non-communicable diseases, depression, anxiety, financial stress, and experiences of or apprehension about HIV-related discrimination. We propose adding a ‘fourth 90’ to the testing and treatment target: ensure that 90 % of people with viral load suppression have good health-related quality of life. The new target would expand the continuum-of-services paradigm beyond the existing endpoint of viral suppression. Good health-related quality of life for PLHIV entails attention to two domains: comorbidities and self-perceived quality of life.

Conclusions:
Health systems everywhere need to become more integrated and more people-centered to successfully meet the needs of virally suppressed PLHIV. By doing so, these systems can better meet the needs of all of their constituents – regardless of HIV status – in an era when many populations worldwide are living much longer with multiple comorbidities.

Keywords:
AIDS HIV Health policy Health systems


Autoři: Jeffrey V. Lazarus 1,2*;  Kelly Safreed-Harmon 2;  Simon E. Barton 3;  Dominique Costagliola 4;  Nikos Dedes 5;  Julia Del Amo Valero 6;  Jose M. Gatell 7;  Ricardo Baptista-Leite 8,9;  Luís Mendão 5;  Kholoud Porter 10;  Stefano Vella 11;  Jürgen Kurt Rockstroh 12
Působiště autorů: ISGlobal, Hospital Clinic, University of Barcelona, Barcelona, Spain. 1;  University College London, London, UK. 10;  Global Health, Istituto Superiore di Sanità, Rome, Italy. 11;  Department of Medicine I, University Hospital Bonn, Bonn, Germany. 12;  Centre for Health and Infectious Disease Research (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. 2;  Imperial College, London, UK. 3;  Sorbonne Universités, INSERM, UPMC Univ Paris 0 , Institut Pierre Louis d’épidémiologie et de Santé Publique, F7 013 Paris, France. 4;  European AIDS Treatment Group, Brussels, Belgium. 5;  Instituto de Salud Carlos III, Madrid, Spain. 6;  Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain. 7;  Universidade Católica Portuguesa, Lisbon, Portugal. 8;  Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands. 9
Vyšlo v časopise: BMC Medicine 2016, 14:94
Kategorie: Opinion
prolekare.web.journal.doi_sk: 10.1186/s12916-016-0640-4

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
The electronic version of this article is the complete one and can be found online at: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0640-4

Souhrn

Background:
In 2016, the World Health Organization (WHO) adopted a new Global Health Sector Strategy on HIV for 2016–2021. It establishes 15 ambitious targets, including the ‘90-90-90’ target calling on health systems to reduce under-diagnosis of HIV, treat a greater number of those diagnosed, and ensure that those being treated achieve viral suppression.

Discussion:
The WHO strategy calls for person-centered chronic care for people living with HIV (PLHIV), implicitly acknowledging that viral suppression is not the ultimate goal of treatment. However, it stops short of providing an explicit target for health-related quality of life. It thus fails to take into account the needs of PLHIV who have achieved viral suppression but still must contend with other intense challenges such as serious non-communicable diseases, depression, anxiety, financial stress, and experiences of or apprehension about HIV-related discrimination. We propose adding a ‘fourth 90’ to the testing and treatment target: ensure that 90 % of people with viral load suppression have good health-related quality of life. The new target would expand the continuum-of-services paradigm beyond the existing endpoint of viral suppression. Good health-related quality of life for PLHIV entails attention to two domains: comorbidities and self-perceived quality of life.

Conclusions:
Health systems everywhere need to become more integrated and more people-centered to successfully meet the needs of virally suppressed PLHIV. By doing so, these systems can better meet the needs of all of their constituents – regardless of HIV status – in an era when many populations worldwide are living much longer with multiple comorbidities.

Keywords:
AIDS HIV Health policy Health systems


Zdroje

1. World Health Organization. Draft global health sector strategy on HIV, 2016–2021 [Draft 01.12.2015]. 2015. http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_31-en.pdf?ua=1. Accessed 25 April 2016.

2. UNAIDS. 90–90–90: an ambitious treatment target to help end the AIDS epidemic. 2014. http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf. Accessed 25 April 2016.

3. Costagliola D. Demographics of HIV and aging. Curr Opin HIV AIDS. 2014;9: 294–301.

4. Kooij KW, Wit FWNM, Van Zoest RA, Schouten J, Kootstra N, Van Vugt M, et al. Liver fibrosis in HIV-infected individuals on long-term antiretroviral therapy: associated with immune activation, immunodeficiency and prior use of didanosine. AIDS. 2016. Epub ahead of print.

5. Schouten J, Wit FW, Stolte IG, Kootstra NA, van der Valk M, Geerlings SE, AGEhIV Cohort Study Group, et al. Cross-sectional comparison of the prevalence of age-associated comorbidities and their risk factors between HIV-infected and uninfected individuals: the AGEhIV cohort study. Clin Infect Dis. 2014;59:1787–97.

6. Schouten J, Su T, Wit FW, Kootstra NA, Caan MWA, Geurtsen GJ, AGEhIV Study Group, et al. Determinants of reduced cognitive performance in HIV-1-infected middle-aged men on combination antiretroviral therapy. AIDS. 2016;30:1027–38.

7. Erdbeer G, Sabranski M, Sonntag I, Stoehr A, Horst HA, Plettenberg A, et al. Everything fine so far? Physical and mental health in HIV-infected patients with virological success and long-term exposure to antiretroviral therapy. J Int AIDS Soc. 2014;17(4 Suppl 3):19673.

8. Miners A, Phillips A, Kreif N, Rodger A, Speakman A, Fisher M, ASTRA (Antiretrovirals, Sexual Transmission and Attitudes) Study, et al. Healthrelated quality-of-life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population. Lancet HIV. 2014;1:e32–40.

9. UNAIDS. UNAIDS 2016–2021 strategy: on the fast-track to end AIDS. 2015. http://www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf. Accessed 25 April 2016.

10. Ingle SM, May MT, Gill MJ, Mugavero MJ, Lewden C, Abgrall S, Antiretroviral Therapy Cohort Collaboration,et al. Impact of risk factors for specific causes of death in the first and subsequent years of antiretroviral therapy among HIV-infected patients. Clin Infect Dis. 2014;59:287–97.

11. van Lelyveld SFL, Gras L, Kesselring A, Zhang S, De Wolf F, Wensing AMJ, ATHENA national observational cohort study, et al. Long-term complications in patients with poor immunological recovery despite virological successful HAART in Dutch ATHENA cohort. AIDS. 2012;26:465–74.

12. Moh R, Danel C, Messou E, Ouassa T, Gabillard D, Anzian A, et al. Incidence and determinants of mortality and morbidity following early antiretroviral therapy initiation in HIV-infected adults in West Africa. AIDS. 2007;21:2483–91.

13. Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90-90-90 target be achieved? Analysis of 12 national level HIV treatment cascades. 8th IAS Conference on HIV Pathogenesis, Treatment & Prevention. 19–22 July 2015. Vancouver, BC, Canada. Oral abstract MOAD0102.

14. Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plan. 2014;29 Suppl 2:ii1–5.

15. Alleyne G, Binagwaho A, Haines A, Jahan S, Nugent R, Rojhani A, et al. Embedding non-communicable diseases in the post-2015 development agenda. Lancet. 2013;381:566–74.

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