Progress and challenges in implementing HIV care and treatment policies in Latin America following the treatment 2.0 initiative

Type and total number of recommendations per country

Ecuador and Bolivia received the highest number of recommendations (29 each), followed
by Honduras (n?=?28) and Argentina (n?=?20). The technical priority areas where the largest number of recommendations were
focused were those corresponding to optimization of ART regimens (n?=?57), followed by rational and efficient use of resources (n?=?27) and provision of POC diagnostics and monitoring tools (n?=?26) (Table 1). The review of the type of recommendations most frequently included in each technical
priority area revealed the trends here below:

Table 1. Treatment 2.0 Joint Technical Missions in Latin America. Type and number of recommendations
by country (2012–2013)

Optimization of ART Regimens:

the following recommendations were present in the eight countries where the monitoring
was conducted: 1) to promote the use of regimens of simplified, less toxic drugs that
maintain therapeutic efficacy, thus pointing to the need of updating the recommended
therapeutic regimens with preferred first-line treatment with TDF?+?3TC (or FTC)?+?EFV
in a fixed dosage combination (FDC) for adults and adolescents; 2) the recommended
second-line treatment should include two nucleoside reverse transcriptase inhibitors
plus a protease inhibitor reinforced with ritonavir (AZT/3TC [CDF])?+?ATV/r (or LPV/r)
and; 3) the need to gradually phase out ARVs due to their toxicity profile (e.g. stavudine
[d4T]) with a migration plan accompanied by an information and communication strategy.
In seven of the eight countries, updating the national ART and treatment guidelines
(or finalizing this process) was recommended.

Provision of Access to POC Diagnostics and Monitoring Tools

four of the eight countries received the following recommendations: 1) the need to
develop and implement HIV diagnosis strategies to include POC technologies that would
make it possible to expand HIV testing and counseling, mainly at the primary and community
level; 2) the use and decentralization of the viral load test as the preferred method
for confirming treatment effectiveness and for diagnosis of treatment failure; 3)
to decentralize the use of CD4 as a method for evaluating eligibility for ART and
for patient monitoring.

Rational and efficient use of resources

in seven of the eight countries the following steps were recommended: 1) to adapt
the drug and supply management plans considering the services available under the
PAHO Strategic Fund, which is a mechanism that facilitates the procurement of strategic
public health supplies and materials to the Member States of the Region of the Americas;
and 2) to review the methodology for estimating country needs of drugs, supplies and
laboratory tests.

Adapt Delivery Systems:

the key recommendation in this priority area was related to the need to deconcentrate,
decentralize and integrate the ART program at all levels of the healthcare system
in four of the eight countries visited.

Community Mobilization:

two recommendations were highlighted in this topic: 1) in five of the eight countries
there is a need to design and implement communication strategies in order to provide
information about the Treatment 2.0 initiative and its priority areas in different
national contexts; 2) in three of eight countries it was recommended to involve and
engage key populations and people living with HIV in the planning, delivery and evaluation
of HIV treatment and care programs. This includes inter alia prevention interventions
and support for ART adherence.

Strategic Information:

an identified need was to strengthen the information systems in each country in order
to have a complete overview of the national cohort of patients in care and treatment
including the treatment cascade and plan appropriate and timely interventions. In
some countries it is necessary to evaluate and make necessary changes in the existing
HIV information systems (MANGUA in Guatemala, CENAVAFELS in Venezuela, and SEGAMI
in the Dominican Republic).

Results of the structured interviews

Overall, representatives from national ART program and international cooperation from
each of the four countries completed the questionnaire. Civil society representatives
from Ecuador and El Salvador who were identified and agreed to respond to the survey
did not submit the completed questionnaire even after various reminders. The reason
for this was not established. No incoherent answers were found.

Analysis of the implementation of the Treatment 2.0 initiative in each country

Ecuador

Representatives of the National AIDS Program (NAP) and PAHO responded to the survey
for Ecuador. The perception of compliance with the recommendations for each priority
area of the Treatment 2.0 initiative in Ecuador shows that most progress was made
on the optimization of ART regimens (70–72 %), while the least progress was made on
the provision of implementing access to POC diagnostics and monitoring tools (32 %).
With the exception of the optimization of ART regimens priority area, none of the
other priority areas exceeded 50 % in terms of perception of their implementation
(Fig. 1). When examining the optimization of ART regimens priority area, the main recommendation
concerned updating the ARV treatment guidelines, together with updating the first
and second-line standardized regimens and withdrawing non-recommended drugs (Fig. 2). Finally, both the NAP and PAHO representatives agreed with the perception that
little progress had been made in the POC diagnosis priority area implementation (20–40
%) (data not presented).

Fig. 1. Follow-up of the Treatment 2.0 Strategy in Ecuador (29 recommendations)* and Venezuela
(20 recommendations)
^±
: perception of the compliance of recommendations by key informants

Fig. 2. Perception of the compliance of the recommendations regarding the optimization of
antiretroviral regimens by representatives of the National AIDS Programof Ecuador
and the country PAHO office*

Venezuela

A representative of the NAP and international cooperation representatives for Venezuela
(PAHO and UNAIDS) responded to the survey, while it was not possible to gauge the
opinion of civil society in order to complete the exercise. The PNS considered that
most progress had been made in the community mobilization priority area (92 %), followed
by the rational and efficient use of resources priority area (85 %). Meanwhile, representatives
from the international cooperation agreed that much progress was evident in the rational
and efficient use of resources and optimization of ART regimens (both 70 %), followed
by community mobilization (60 %). A significant difference between the respondents
was observed in the perception of progress in the adaption of delivery service priority
area: the NAP perceived a progress of 60 %, while international cooperation representatives
cited that progress was zero. (Fig. 1). Both key informants interviewed agreed that progress on implementation of the recommendations
on strategic information was low (20 % NAP, 40 % international cooperation). The strategic
information recommendations were perceived by the interviewees to have made limited
progress (data not presented).

Bolivia

The monitoring survey for Bolivia was completed by representatives of the NAP, PAHO
and civil society. Fig. 3 illustrates the perception of the progress made by the Treatment 2.0 initiative in
this country under each priority area. Both NAP and PAHO had a general perception
of greater progress than was perceived by civil society. Progress in the optimization
of ART regimens priority area scored an average of 79 %, while rational and efficient
use of resources was rated at 75 %. The lowest average scores were in the provision
of POC diagnostics and monitoring tools (41 %) and community mobilization (40 %) priority
areas.

Fig. 3. Follow-up of the Treatment 2.0 Strategy in Bolivia (28 recommendations)* and El Salvador
(12 recommendations)
^±
: perception of the compliance of recommendations by key informants

El Salvador

Representatives of the National AIDS Program, PAHO and civil society responded to
the survey for El Salvador. There were no recommendations for the provision of POC
diagnostics and monitoring tools priority area, nor for community mobilization. The
area with most recommendations was for the optimization of ART regimens (n?=?9), where all interviewees concurred that progress had been made (average 55 %).
On the other hand, there was a notable difference between the interviewees’ perception
of progress in the two priority areas rational and efficient use of resources and
strategic information (ranging from 20–100 %) (Fig. 3).

Comparative analysis of the implementation of each priority area in the different
countries

In the four countries where structured interviews were conducted, most perceived progress
was made in the rational and efficient use of resources priority area where average
progress was perceived to be 62 %, followed by the optimization of ART regimens priority
area (average 59.7 %). Meanwhile, progress in the priority areas of the adaption of
delivery systems, community mobilization, and strategic information were rated at
52 %. Finally, the provision of POC diagnostics and monitoring tools scored the lowest
(an average of only 38 %).

The optimization of ART regimens priority area received an overall average rating
of 60 % progress in the four countries (Fig. 4). Detail review of this area showed scores for the recommendation on updating ART
guidelines with an 80–100 % progresses in three of the four countries (El Salvador
was rated at 60 %). The least progress perceived was related to the recommendation
on plans of communication related to the optimization of ART regimens (0–60 %) and
ART migration plans (30–60 %) (data not presented).

Fig. 4. Follow-up of the Treatment 2.0 Strategy in four countries of Latin America. Comparative
perception of the compliance of recommendations related to optimization of antiretroviral
regimens and provisions of point-of-care diagnostics*

Limited progress was perceived in the priority area of provision of POC diagnostic
and monitoring tools (less than 50 % in all the countries; average?=?38 %) (Fig. 4). Although the updating of diagnostic algorithms, with the inclusion of HIV rapid
tests, was the most common recommendation, it was perceived to have progressed by
only 46 % on average. Meanwhile, the recommendations with the lowest levels of perceived
progress were the decentralization of monitoring tests (viral load and CD4), averaging
20 %, and the inclusion of sample transportation strategies, with a perceived 22 %
average of implementation (data not included in the graphic).

No recommendations were made on the ‘adaptation of delivery services’ priority area
for El Salvador. Of the three remaining countries, Bolivia reported the highest average
progress in this area (average 66 % based on responses from all key informants), although
there was a substantial gap between interviewees (72 and 78 % for PAHO and NAP respectively,
compared to 49 % for civil society). Venezuela had the lowest average perceived progress
in this priority area (30 %), although civil society did not respond to the survey.
Note that the Venezuelan NAP representatives perceived 60 % progress, while the international
cooperation perceived no progress at all. (Fig. 5). The most frequent recommendation in this priority area was the decentralization
of health care programs for which the perceived average implementation was scored
at 50 % although this was reported in only two countries (Bolivia and Ecuador). The
number of recommendations in this priority area was different in each of the four
countries: seven recommendations were made for Bolivia, two for Ecuador, one for Venezuela
and none for El Salvador.

Fig. 5. Follow-up of the Treatment 2.0 Strategy in four countries of Latin America. Comparative
perception of the compliance of recommendations related to adaptation of delivery
services and strategic information*

Recommendations on community mobilization were made in only three countries. Progress
achieved in this priority area was on average 50 %. However, it was not possible to
obtain a realistic view of the implementation of this priority area in Venezuela and
Ecuador since civil society (the main beneficiaries) did not participate in the survey,
thereby limiting the value of the analysis. Despite this, Venezuela was perceived
to have made progress in terms of community participation (76 %), followed by Ecuador
(46 %) and Bolivia (40 %). The most frequent recommendation in this priority area
was the need to implement communication and training strategies for civil society,
designed to improve understanding and monitoring of the implementation of recommendations
related to the other priority areas. The average progress of implementation was perceived
at 54 % (data not presented). Implementation of the strategic information recommendations
averaged 50 %. El Salvador and Bolivia had the highest perception of progress in this
priority area (both with an average of 60 %) (Fig. 5). The most common recommendations in this area were the inclusion and updating of
the HIV information system in the general health information systems. The implementation
of both recommendations was perceived to have progressed by an average of 30 %.

Quantitative analysis of the optimization of ARV use

A summary of the results of the analysis of the optimization of antiretroviral use
in El Salvador, Venezuela and Bolivia is presented in Table 2. The quantitative analysis shows that there was a 36 % reduction in the average number
of first-line ART regimens in use, from 11 in 2012 to seven in 2013. A similar trend
can be observed for the second-line ART regimens. Over the same period, the proportion
of patients on first-line regimens recommended by WHO increased from 74–78 % (5.4
% increase). The average use of the preferred WHO first-line ART regimen [TDF?+?3TC
(or FTC)?+?EFV] increased from 36–43 % (19.4 % increase) between 2012 and 2013 (it
should be noted that for this indicator, results are discordant among countries and
in Venezuela the use of the WHO preferred regimen declined from 63–43 % over the same
time period). In addition, average use of the WHO preferred second-line ART regimens
[AZT?+?3TC (or TDF?+?XTC)?+?LPV/r (or ATV/r)] increased from 43–65 % (51 % increase)
between 2012 and 2013. It is also noteworthy that there was a reduction in the use
of obsolete ARV in first-line regimens. In 2013, only 1 % of people receiving first-line
ART were still on regimens with didanosine (ddl) (no d4T-based regimen was reported).
Finally, a reduction in the use of obsolete ARVs in second-line regimens was reported
during the period under study. In 2013, 9 % of individuals on second-line ARV were
still on regimens with ddl (no d4T-based regimen was reported).

Table 2. Optimization of ARVs in the three countries of Latin America, 2012-2013