The response to the global Human Immunodeficiency Virus (HIV) rife is at a precarious level. For nearly half a century, the Virus has been an epidemic that has beleaguered the global population. However, HIV-AIDS related number of deaths is at the lowest level in this century. This has been attributed to the sustained access of the antiretroviral drugs along with its therapy. Antiretroviral drugs together with the Pre-Exposure Prophylaxis (PrEP) has significantly lowered the prevalence of HIV and reduced the number of people who succumb to the virus to less than one million people annually. This is a chasm from the 2016 United Nations (UN) set targets of minimizing the deaths from the Virus and averting new infections by 2030. The pace towards achieving this target has regressed and preventing new infections has not transcended complacency especially in the bleak economies. Towards the end of 2001, HIV had been declared a global epidemic. Approximately 40 million people were living with the virus worldwide, with a significant number of these people from the sub-Saharan African who had circa 28.1 million people surviving with the virus respective with the statistics compiled by UNAIDS (UNAIDS, ). The UN has set up strategies in an attempt to combat this through the Fast-Track tactic to PrEP distribution with a prime target of reaching approximately 3 million people that are on PrEP by the end of 2020.
Well, the timeline of achieving this is fast approaching and it is candid that the UNAID is not matching its expected target projection in battling this endemic. It is essential to try and comprehend why PrEP is not being effectively distributed in the areas where the prevalence rates are spiking and in comparisons with the regions where new infections are significantly reducing.
The current statistic demonstrates the margin in which UNAID has missed its mark, figuring out the mechanisms, training necessities and all kind of techniques that should be implemented to bridge this gap is inevitable if we really need to eradicate this pandemic. Clearly, we can use the techniques that have exceptionally worked in Northern America especially in the USA and replicate this in other regions such as Eastern Europe and Central Asia where new HIV-AIDS related deaths and new infections are escalating
In this paper, I will outsource my statistics from the Joint United Nations Program on HIV/AIDS. Also, I will center my studies on the heightened prevalence rates in central Asia and Eastern Europe together with the published articles that study the same challenge in Europe. Critical comparisons and contrasting of the data of regions experiencing distinct outcomes will aid us in comprehending why some countries are not successful in minimizing the number of infections to achieve the goals that have been set by UNAID and why certain states have been significantly successful in decreasing their prevalence rates.
Current Evidence.
Well, it is impossible to disregard the fact that the assimilation of PrEP therapy in HIV diagnosis has significantly reduced the prevalence of HIV. Even more so, it is astonishing to imagine the exceptional targets we will achieve in combating this plague given stronger support and increased education levels. However much we may be fascinated to imagine this, the reality is far from that thought! The progressive pace that is being used to combat the transmission of HIV is frustrating and not happening hastily. Since the year 2010, statistics indicate that the total number of new HIV infections have reduced to 1.8 million infections a 16% decline. This demonstrates how slowly we are advancing to meet the Fast-Tract goal of less than half a million infections by 2020. Comparably HIV/AIDS deaths have reduced by a 48% margin since 2010. This was a shift from approximately two million deaths per annum to one million. This figure implies that there are approximately five thousand new HIV infections daily, where four hundred are children who are aged fifteen years and below. The distribution of PrEP therapy is startling, as it is mostly centered in Northern America where the victims are roughly 59% of the total approximate of five hundred thousand people. Still, these figures are way below the UNAID target for the year 2020. Whereas we can be contented in North America where the risks of being infected with the virus have been combated effectively, there is alarming statistics from central Asia and the Eastern Europe which indicate the increased number of new infections to wearisome levels, rising by 60% (UNAIDS Data 2018, 2018, p. 06).
There is a severe scarcity of health-care practitioners together with continued discrimination and stigmatization in central Asia and Eastern Europe which has really harmed the prevention of the crisis. The success rate in saving lives has not been equivocal with the rate of averting new infections. HIV prevention, care, and services are not being offered inadequacy and with sufficient intensity. As such, these services do not reach the individuals who need them the most especially those in Asia and part of the former Soviet nations. An article recently warned that a loftier pandemic in these Soviet counties, “may be imminent”. Ukraine for instance, while the HIV transmission rate is alarming as a result of sharing syringes and prostitution there has been a strategic shift to the rest of the bigger population (Ian Fisher, The New York Times, 2002,). Nonetheless, the sudden spikes in the HIV prevalence throughout Africa, central Asia, and Eastern Europe have attracted the world’s attention. Around these regions the rate on new infections is fifteen times more than three years ago this has been as a result of the younger people endorsing intravenous usage of drugs (Northridge, 2002).
Using PrEP, condoms acceptance, and male circumcision practice need to be rapidly increased and not perceived as secondary prevention mechanisms. Although 1.4 million new infections have been deterred, children have been forgotten in these efforts. During the year 2017, 180,000 children were infected with HIV which is miles away from the 2018 target which was to eradicate new HIV infection among children. Whereas the general and overall treatment of HIV is at peak, the prejudice committed against these kids is devastating considering only half of the children under the age of fifteen were receiving treatment last year.
Stern discrimination and stigmatization have severe consequences. The very person who is supposed to be fully supporting, protecting, and providing treatment to individuals living with the virus often alienate and stigmatize these victims who should be in their prime care, not providing them access to essential HIV care and services. As a result, they are exposed to more HIV infections escalating their death rates. Each state is responsible for the protection of its citizens. Human rights are global rights and nobody should be excluded, not gays, people who use drug injections, transgender individuals, immigrants, prisoners, or sex workers. There is still the existence of bad laws which criminalize the transmission of HIV, sex work, and sexual orientations which must be abolished. Girls and women have unduly been affected continuously. It is insane to imagine that one in three women globally has undergone sexual or physical violence. We cannot slip up our efforts to deal with these and root out any kind of abuse, sexual violence or harassment. UNAIDS has stood firm in the commitment of eradicating this wherever they occur. There have been significant strides in the treatment and diagnosis of HIV among individuals with tuberculosis. Nonetheless, still, nearly half a century into the HIV pandemic, three in five individuals who are initiating HIV treatment are not tested, screened or treated for tuberculosis, which is the major killer of individuals who is living with HIV. It is essential to integrate HIV care and services together with sexual orientation and reproductive health services. This should be accompanied by establishing robust links with services for diseases that are non-communicable. UNAIDS prime target has to be saving lives holistically and not disease wise or tolerating any kind of isolation of a disease. There has been insufficient funding for battling this plague. We may appreciate the reality that there was increased funding and resources that were allocated for AIDS in 2017 but still there is a 20% deficit from what is needed to what has been availed. The fact that we cannot be able to afford any kind of cuts in the assistance from the international bodies towards AIDS response is also deterring. Slashing 20% allocation of international funding will be disastrous for the forty-four countries that are dependent on international aid. This is because these funds account for nearly 75% of their country’s national AIDS responses. AIDS responses package kit should be fully funded, as is the universal health coverage resource allocated. The UNAIDS 2018, 2019 Data highlights, effectively demonstrate this challenge and some success based on these funding.
From the start of 2010 deaths that are AIDS-related have reduced by a sheer margin of 34% and achieving the milestone set 2020 will require a huge and rapid decline of approximately 150,000 deaths annually. Notably, we have had significant declines in AIDS-related deaths in Asia and the Pacific experiencing a 39% decline. Western, central Europe together with North America have had a 36% prevalence reduction and the Caribbean experiencing a 23% decline. In South America where the ARV drugs and therapy usage has been significantly high, deaths related to AIDS have been reducing over the last seven years and its reduction rate has been 12%. Well, this has not been the case in Eastern Europe and central Asia as there has not been any mortality reduction that is AIDS-related since 2010. Nevertheless, there has been increased deaths resulting from AIDS-related diseases by 11% in the Middle East. From the (UNAIDS 2018, 2019) data, which compile special surveys of the major population based on the response-driven random sampling technique, 47% of the new infections were made up of the key population together with their sexual counterparts. This rate, however, differs with every region or country. The key population together with their sexual partners significantly contributed more than 95% of the infections in central Asia and Eastern Europe.
In 2017 men who have sex with fellow men as well as gay men significantly contributed to the spread of HIV. In Western and Central Europe as well as North America, these individuals contributed an estimated fifty-seven percent of new infections. In the same year, these people contributed forty-one percent of the new infection in Latin America, over twenty-five percent in the Pacific, Asia and Caribbean, and twenty percent in Central Asia, Eastern Europe, North Africa, and the Middle East. According to the Spanish National Aids Plan, this trend can only be reversed if enough promotion on use of condoms, testing for HIV, quick access to post-exposure Prophylaxis (PREP), and Antiretroviral Therapy (ART) are done. According to (Iniesta et al., 2018), the group of men who have sex with men (MSM) does not consistently use condoms during sexual intercourse and that puts them at very high risk of HIV infection. Generally, the undiagnosed HIV infections among people living with HIV (LWHV) are estimated to range between 14 and 22%. Efforts have been put to ensure that free PrEP is accessible in public hospitals. However, its utilization levels are low due to lack of awareness which further accelerates the effects of HIV virus.
To this end, PrEP is an effective preventive measure for HIV. However, it is unfortunate that it has not been formally implemented in some parts of Europe. For instance, Spain has not formally made PrEP available to the public which further explains why Europe is lagging behind in meeting the UNAID HIV eradication target. European Medicine Agency has approved the commercial use of a combination of Pre-exposure prophylactic and tenofovir which has been implemented by most European countries that have similar epidemiological outlines with Spain. This has proven to be safe, effective and economical. According to the National Ethics Committee, The Spanish Scientific Clinical Society for Aids, and the National AIDS Plan at the Ministry of health, PrEP use should be in areas and populations that are at a heightened risk of being infected with HIV precisely transgender women and the MSM group. Despite these recommendations, Spain’s Ministry of health and other correspondent health authorities in self-ruling populations have not effected PrEP and as such it is unavailable in Spanish Health System (Iniesta et al., 2018).
Integrating PrEP with a wide range of other programs including HIV testing, providing early treatment for HIV infected individuals, and other prevention methods discussed above are promising pieces of evidence for many European countries which are suffering from increasing incidences of HIV. As a result, there is an increased demand for low-priced and wider delivery of PrEP. Currently, most of the people who use PrEP in Europe are the MSM group, gay people, and bisexual men. These people are highly vulnerable to HIV infections and are basically knowledgeable, motivated, and have support from the concerned clinicians as well as the civil society. Nonetheless, even in areas where PrEP programs are deep-rooted and are taken-up by poorly empowered communities, establishing wide distribution and use of PrEP is still a challenge (Coleman & Prins, 2017).
All PrEP programs should also provide solutions to stubborn barriers and uncertainties such as an estimation of the number of people suitable for PrEP, PrEP medication price, PrEP resistance risk, disapproval and unacceptance of PrEP by some members of crucial communities and some healthcare workers. Although there have been promising efforts to meet these fears, persistent doubt decreases estimations of economical PrEP prices and prevents wider implementation plans. As a result, many countries and precisely in Eastern Europe are in dilemma of how to apply and establish cost-effective PrEP programs at a national level in a manner that meets the needs, reduces the potential adverse impact and still be within the means of the country. Safe integration of PrEP with additional community and sexual services have the ability to elicit the combined benefits of PrEP admittance (Coleman & Prins, 2017).
In Asia-Pacific, the levels of PrEP use are also low. Nonetheless, most of the MSM individuals who know about PrEP have agreed to use it. Implementation of PrEP in Asia-Pacific has been hindered by a number of factors including insufficient PrEP knowledge, inadequate PrEP access, pathetic or lack of programs to prevent HIV infections to MSM and other vulnerable groups, strict laws in certain nations, discrimination and stigmatization of vulnerable populations and most importantly high costs of PrEP (Zablotska et al., 2016).
Asia is another continent that is reportedly behind the UNAID target of HIV eradication. In countries such as Thailand and Australia, the number of clinical trials, illustration schemes and extensive studies which has been implemented so far is limited. Nonetheless, innovative ways for implementation of PrEP have been developed. These include facilities for research and care models led in communities which offer PrEP services for free or at a fee. To maximize the use of HIV prevention the World Health Organization consolidated guidelines for HIV prevention, testing, and treatment has called for an expansion of PrEP availability and has given the procedures for PrEP execution in these areas. Although Australia has produced the national guidelines for implementation of PrEP, and there is rising community leadership and PrEP implementation consultation processes in the Pacific and Asia, these regions are still lagging behind the UNAID target thereby contributing to the global missed UNAIDs target.
Five years ago, Asia-Pacific held over half of the global population and out of the thirty-six point nine million people living with HIV, fifteen point two percent of them lived in this region. The countries that have recorded the highest percentage of PLWHV (90%) reside in five countries namely: Vietnam, China, India, Thailand, Indonesia, and India. The rise of HIV in these nations is contributed by the increase in HIV vulnerable populations including the MSM group and precisely the young men in this group and those men who are moving to MSM which is the leading mode of HIV transmissions.
Since the authorization of PrEP by the US Food and Drug Administration four years ago, the US has shown remarkable implementation and uptake of PrEP. However, PrEP implementation in certain regions of the world such as the Asia-Pacific remains limited due to several challenges. Despite the increased awareness of PrEP, the pace and level of growth remain inadequate for the production of substantial services that meet the demands. It is important to escalate PrEP education in the populations around these regions. The availability of PrEP in the Asia-Pacific is still a big deal. Providing access to Antiretroviral Therapy to the eligible individuals is still a struggle in most countries in this region. Although some countries such as Thailand and Cambodia have made substantial progress in respect to people who are eligible for ART, nations which have a high number of ART-eligible individual according to the 2010 World Health organization HIV guidelines are still lagging behind.
HIV testing forms the primary base for HIV prevention and treatment. However, in these region HIV testing coverage especially in MSM individuals is still low. 2013 testing data indicated less than 50% testing of MSM group in the majority of these countries. The main barriers in ensuring community HIV testing outreach reaches the MSM group in the majority of the countries include the absence of community-based testing programs and lack of policies that can facilitate the laying and provision of peer testing. Although HIV self-testing has the ability to reach individuals who lack access to health care services and is easily available through the internet and pharmacies, this strategy is not integrated into the national HIV testing regulations. Besides, the majority of nations lack quality assurance schemes to regulate and ensure that the public receives quality testing services.
In other nations such as the Philippines, Myanmar, and Cambodia, ancient punishing laws remain in action. These laws contribute to discrimination and stigmatization of the sidelined groups which remain as collective barriers against PrEP implementation. However, some countries such as Vietnam has put promising efforts to ensure the elimination of discrimination and stigma. For instance, Vietnam Health Insurance law is anticipating to offer coverage of the HIV- associated expenses for the poor and the near-poor individuals at a hundred percent and ninety-five percent rate respectively.
Another major barrier to achieving the UNAID target is the cost of ARVs. For instance, in most of the Asian countries, the high cost of medication prevent the availability of ARVs in hubs that are not accredited by the government. In other countries such as Malaysia, Thailand, Singapore, and Vietnam ARVs are only available in private organizations which makes them more expensive thereby reducing their reach to the marginalized groups. PrEP access is highly affected by issues of drug pricing and licensing. E.g. Australian regulatory authorities have not yet sanctioned generic TDF. Although the product is manufactured in the region, it is not recorded as a preventive measure in the region yet.
Further, the fast implementation of PrEP in the majority of the countries in this region is also affected by ARV access restrictions as a result of the complex intellectual property regulations. In the meantime, Thai land has implemented the PrEP-30 projects which provide PrEP based services at a fee. In May 2016 Australia approved the use of TDF/ FTC as a preventive measure. Nonetheless, Australia should make sure that the service is affordable to every Australian by ensuring that the national pharmaceutical Benefit Scheme approves the medication. Despite the fact that PrEP has been made available in these countries, there lacks enough guidance on how these countries can target PrEP to the most vulnerable groups. In Asia-Pacific, the MSM group and other crucial populations are highly infected with HIV. However, the general data about incidences of HIV in the blood serum is lacking which could be used as a base for eligibility criteria for targeting MSM.
World Health Organization Guidelines for preventing, testing and treating of HIV requires to promote the expansion of PrEP access. The Asian continent has recorded an increasing rate of HIV infections. Although there are efforts to ensure that PrEP is accessible to all in the continent, there is no single country in this region that offers PrEP services for free to the high-risk groups. This is one of the reasons why PrEP coverage has not met the UNAIDs target. Nonetheless, countries like Thailand and Australia have established scale-up PrEP execution projects which offer free PrEP services to just a few participants. Some other Projects related to PrEP access such as the Bangkok PrEP-30 project offer PrEP services at a normal fee. However, PrEP programs have not been made permanent even in countries with high income. Therefore, it is important to ensure that permanent solutions are offered in regards to PrEP access Programs, costs of Truvada, and an extensive availability and access to generic TDF/FTC.