Issue 24  December 2010

HIVUpdate
Contents
1 Adherence 4 Life 4 People at IPPF: Hong Kakada
2 Treatment 2.0: Therapeutic and prevention 4 News in brief
benefits of ART 4 New publications
3 Adherence: More than just about taking pills 4 Events and key dates

ADHERENCE 4 LIFE
Taking any routine
medication on a regular
basis is challenging for us
all. More so if the regimen is
life-saving and adhering to it
requires a life-long commitment.
With antiretroviral treatment
(ART) reaching more people
than ever, many more are now
facing this challenge. As the
world recognizes both World
AIDS Day (1 December) and
International Human Rights Day
(10 December), it is important to
ensure that our programmes are
improving and maintaining the
health and well-being of people
living with HIV, including support
for treatment adherence.
As treatment reduces a
person’s viral load, it also
reduces the risk of onward HIV
transmission. This evidence
shows that treatment should be
part of a combination prevention
strategy or ‘treatment as
prevention’ approach. Starting
treatment earlier means that viral
load can be reduced earlier and
this, in turn, can help to avert a
significant number of new HIV
infections. This is one aspect of
the new ‘Treatment 2.0’ platform
introduced by WHO and UNAIDS
(see page 2).
In 2010, WHO introduced
updated guidelines promoting
the earlier initiation of treatment,
adding an estimated five million
people who are now eligible for
treatment. With more people
receiving treatment, there is
growing emphasis on issues
such as treatment retention and
resistance. Once treatment is
no longer effective, it may be
necessary to move to second-
or third-lines of treatment – a
luxury still not widely available in
many low- and middle-income
countries.
However, reflections by
Dr. Ashraf Grimwood – CEO
of Kheth’Impilo and a leading
HIV clinician in South Africa
for many years – indicates that
adherence is more than just
about taking pills (see page 3).
While scientists develop new
treatment options to improve
the effectiveness and ease of
use, IPPF needs to provide further
support to people living with
HIV – in ways big and small – to
help increase overall treatment
adherence rates. From supplying
pill boxes and promoting
individual adherence, to scaling-
up community-based support
services and providing adherence
counselling and peer support
– a variety of interventions will
help to realize the promise of
treatment and treatment-centred
HIV prevention.
Love,
Kevin

BEHIND BARS
As part of IPPF’s growing campaign to raise awareness about
issues relating to the criminalization of HIV transmission, a
collection of stories and a short film were launched on World
AIDS Day. By fuelling stigma, criminalization undermines
efforts to prevent, treat and care for HIV.
The Behind Bars interviews and Criminalize Hate Not HIV
video are available at http://bit.ly/criminalization
2 HIV Update  December 2010
Treatment 2.0
Therapeutic and prevention
benefits of ART
By Reuben Granich, Marco Vitoria and Craig McClure
(HIV/AIDS Department, WHO, Geneva)
Despite considerable progress, the global HIV situation remains
serious. By the end of 2009, 5.2 million people were on antiretroviral
treatment (ART); approximately 36 per cent of those estimated to be
in need as per the new WHO recommendations1. This, combined with
the international fiscal crisis, has led to a growing concern regarding a
weakening of the international commitment to universal access and to
reaching the related Millennium Development Goals (MDG) by 2015.
However, there are a number of reasons to be optimistic about our
future efforts to confront HIV.
The 5.2 million people on treatment are a remarkable testament
to the many outstanding examples of programmes that are doing
great work on a large scale. However, our current response to HIV
is often fragmented and unnecessarily complicated. This complexity
often means late initiation of treatment, lack of continuum of care
and increased costs for both programmes and patients. Retention
of patients on antiretroviral therapy, which can mean the difference
between life and death, is often hindered by our current approach to
delivering treatment. Patients, where there is access to treatment, are
often asked to travel great distances, wait in long queues, join lengthy
waiting lists and return frequently to evaluate eligibility for treatment.
When placed on treatment, patients are often asked to adhere to
difficult regimens with little hope of second line treatment in the case
of toxicity or a failure to respond. Drug stock outs are also a stumbling
block for adhering to ART programmes. Prevention, treatment, care
and social support programmes are often in different locations and
could be better integrated in order to effectively use scarce resources.
There is a need to re-examine our approach to delivering prevention
and treatment services to ensure easier access for people living with
HIV.
Two key opportunities have the potential to hasten and expand
the twin goals of saving lives and preventing new HIV infections.
Firstly, the ongoing efforts to develop drug regimens and treatment
What does ‘treatment for prevention’ mean for
IPPF at the country level?
Member Associations could:
• Advocate for countries to review/update their treatment
guidelines.
• Improve uptake of HIV testing and referral.
• Promote and support community-based delivery of outreach
and support services.
• Advocate for human rights of people living with HIV and key
affected populations.
• Link directly – or partner with – PLHIV and key population
networks to increase capacity.
Source: Hirnschall G (2010) Treatment as prevention: What does it mean in
reality? IPPF HIV Competencies Workshop, Vienna, 16 July.
strategies that will render HIV treatment easier to administer, more
efficient to manage, and have a longer lasting impact for individuals
and public health programmes. Secondly, it is also increasingly clear
that universal access to ART can have a significant impact on HIV
transmission. The potential individual and public health prevention
benefits of treatment enhance the value of the universal access pledge
from a life-saving initiative to a strategic investment aimed at ending
the HIV epidemic.
‘Treatment 2.0’ was recently launched by UNAIDS and WHO to
accelerate the simplification of ART in order to achieve and sustain
universal access to treatment for all who need it and realize the
significant potential for HIV and TB preventive benefits. The agenda
of Treatment 2.0 involves radically simplifying drug regimens and
diagnostics and monitoring, decentralizing service delivery, reducing
costs and mobilizing communities.
When combined, expanding access to ART using simpler, more
effective approaches and the use of ART as part of combination
prevention will be critical in reaching the goals of universal access
and will, most likely, result in cost savings over the medium and long
term. Patient-friendly regimens should allow for improved adherence
and increased access and retention to treatment. Our challenge is to
understand how best to use new information regarding the role of
ART for a reinvigorated, more effective and sustainable global response
to AIDS. A simplified, public health approach to treatment is nothing
new. WHO advanced this approach in 2003 to kick-start ART access in
developing countries. Since then, the number of people on treatment
has increased from 50,000 to over 5 million. What is potentially new
is a renewed and intensified focus on simplification with accelerated
expansion and full integration of treatment as a key aspect of HIV
prevention efforts.
1. WHO (2010) Towards universal access: scaling up priority HIV/AIDS
interventions in the health sector. Geneva, WHO. Available at: http://www.
who.int/hiv/pub/2010progressreport/report/en/index.html [accessed 15
November 2010]
Internet resources
• WHO information on antiretroviral therapy
http://www.who.int/hiv/topics/treatment/en/index.html
• NAM HIV treatment information
http://www.aidsmap.com/resources
 December 2010  HIV Update 3

Adherence
More than just about taking pills
By Ashraf Grimwood (Kheth’Impilo,
South Africa)
“I can’t even complete a full
course of antibiotics, how am I
going to remember to take my
ART?”
Adherence is usually understood to
mean ‘the taking of medication as
prescribed’ at the correct time and with the
correct association with meals. But managing
HIV infection is more than just about taking
pills – adherence is about sticking to positive
lifestyle choices.
The impact of HIV starts from the time
of infection and earlier treatment will go
a long way in avoiding complications. But
before starting treatment it is important to
be mentally ready and prepared. I always
recommend to my patients that soon after
diagnosis, regardless of how they feel,
counselling is vital. The usual response is,
“What would I talk about? I know how I
got infected and I know what I need to do!”
I say, “Just go. Talk about anything, give
time to connect with the why and the how,
understand your feelings and see if you can
use this positively.”
The best way of managing an HIV
infection is about making the right lifestyle
choices and, critically, adhering to these.
Adherence is about following lifestyle choices
- irrespective of what they may be - that
ensure the best health outcomes. Regular
monitoring, CD4 counting, STI testing,
exercise and a good dietary plan are crucial
for good health maintenance before even
starting to take pills.
Combination antiretroviral treatment
is the best known way of controlling the
virus. Pills need to be taken as directed by a
clinician. It is important that personal lifestyle
is discussed with a health care worker to
ensure there is no clash. “How do I take my
pills when… I work shift work? I travel often?
I take recreational drugs? I am addicted to
heroin? I am on methadone? I am pregnant?
My partner does not yet know I am HIV
Practical strategies to ensure
adherence
• Think about the demands of adherence
before starting treatment
• Fit pill-taking into a daily schedule
• Divide up doses at the beginning of the
week
• Leave pills where they can be easily
seen
• Plan for changes in schedule or
vacations
• Practise pill-taking beforehand
• Be informed about and prepared for
side-effects
Source: NAM (2010) Improving adherence. In HIV
Treatments Directory. London: NAM. Pp. 204-206.
positive?” These all need to be discussed
with a health care practitioner. It is important
to talk through any life issues that might
impact on treatment adherence. Open honest
communication is always the best option to
ensure better health outcomes.
When starting treatment it is important
to know what is being prescribed – learn the
names, understand what they do, how they
work, what their side effects are and when to
seek professional advice. Ensure treatment is
taken at the times prescribed and know how
much leeway is acceptable with regards to
the timing so the margin of safety is known
when travelling across time zones or working
shifts.
Any day forgotten gives the virus an
opportunity to rebound and any resistant
strain to dominate. This can lead to multi-
drug resistance and treatment failure.
Treatment failure means new drugs need
to be prescribed. All these treatments have
different side effect profiles which need
different management. It is best to remain on
the initial prescribed regimen if there are no
adverse effects.
There are many tools that can be used
to act as reminders for taking pills on time.
Using a daily treatment tick-sheet or diary,
pill boxes, and cell phone reminders are a
few techniques that people have found work
for them. Some take their daily ART at night
after brushing their teeth, so they are often
kept where this is done. Some have spare pills
at their workplace. Packing pill boxes once
a week or getting blister pre-packs for the
month are other strategies that have worked
for some.
All people living with HIV today have
the opportunity to lead as normal lives as
possible with this infection – and adhering
to medication and selected lifestyle choices
is often the starting point. No doubt it’s
hard to stick to these. But being honest with
ourselves and with our clients is always a
great start.

Innovative ideas: communication between health- instructed to respond that either

improving treatment
adherence with text
messaging
A randomized trial in Kenya
has shown that using text
messages to help patients
adhere to their treatment
improves absolute adherence
rates. The study aimed to
assess whether cell phone
care workers and patients
starting antiretroviral therapy in
Kenya improved drug adherence
and suppression of viral load.
Patients in the intervention
group received weekly SMS
messages from a clinic nurse and
were required to respond within
48 hours. The slogan ‘Mambo?’
was sent, which is Kiswahili
for “How are you?” and were
they were doing well (‘Sawa’)
or that they had a problem
(‘Shida’). The clinician then
called patients who said they
had a problem or who failed to
respond within two days.
Source: Lester RT et al. (2010) Effects
of a mobile phone short message
service on antiretroviral treatment
adherence in Kenya (WelTel Kenya1):
a randomised trial. The Lancet, 10
November.
4 HIV Update  December 2010

People at IPPF Hong Kakada RHAC clinics for STI treatment

Project Assistant and Counsellor, MSM: Reproductive
Health Association of Cambodia (RHAC)
For the past six years, I have
worked with various NGOs involved
with men who have sex with men
(MSM) throughout Cambodia. I
joined the RHAC Stoeung Mean
Chey Clinic in Phnom Pehn ten
months ago to work on a project
to increase access to sexual and
reproductive health and HIV
services among MSM. This is
important as the prevalence of HIV
and other STIs among MSM in
and VCT. I also spend a lot of
time in the community and
regularly conduct outreach
activities in the places MSM hang
out together and network, where
Phnom Penh is much higher than
I talk about HIV and other STIs,
the general population.
and provide information on the
Service utilization by MSM is
services offered by RHAC.
low and most hide their identity
As someone who has
because sexual activity between
relationships with other men,
men is still taboo in Cambodian
I am motivated to support
society. I try hard to make the
people from my community to
environment of our clinic as
face the facts and have a better
supportive as possible by treating
understanding of what they need
all service users as good friends. I
to do to protect themselves. I also
believe this friendly environment
want to encourage all MSM in my
has enabled many MSM and
community to work together for
transgender individuals to use
a better life.

News in brief New publications Key dates

Central America and Mexico: Sexual rights in action: World AIDS Day
1 December 2010
Increasing access for most at Case studies from around the world
risk populations (MARPs) Stories which demonstrate why we are fighting for
Sexual rights
International Human Rights Day
As part of a successful collaborative USAID proposal sexual rights. They show how hard it is to live in a in action 10 December 2010
world where your rights are denied, where there
Case studies from around the world

with Population Services International (PSI) to address
the concentrated HIV epidemic in this region, IPPF
Western Hemisphere Region (WHR) will be contributing
technical and implementation assistance to IPPF Member
Associations and other private service providers to
expand direct service provision to most at risk populations
in Mexico, Belize, Guatemala, El Salvador, Honduras,
Nicaragua, Costa Rica and Panama.
International Day to End Violence
is discrimination, stigma and abuse.
against Sex Workers
Available at: http://www.ippf.org/en/Resources/
17 December 2010
Reports-reviews/Sexual+rights+in+action.htm
Towards universal access:
Scaling up priority HIV/AIDS
Upcoming
interventions in the health sector conferences
This report by WHO, UNICEF and UNAIDS reviews 22nd International Harm Reduction
TOWARDS UNIVERSAL ACCESS — Scaling up priority HIV/AIDS interventions in the health sector

Kenya: Adolescents Count Today the progress made in 2009 in scaling up access Conference
(ACT) project to selected health sector interventions for HIV Date: 3-7 April 2011
Family Health Options Kenya (FHOK) has received prevention, treatment and care in low- and Location: Beirut, Lebanon
funding through the Positive Action for Children Fund middle-income countries.
Towards Universal access
For more information, contact:
World Health Organization
Department of HIV/AIDS
Scaling up priority HIV/AIDS interventions
in the health sector
Website: http://www.ihra.net/
by ViiV Healthcare to improve the quality of life of Available at: http://www.who.int/hiv/
ISBN 978 92 4 150039 5
Avenue Appia 20
1211 Geneva 27
Progress Report 2010

conference
Switzerland
E-mail: hiv-aids@who.int
www.who.int/hiv Progress report 2010

8000 adolescents (aged 10-19 years) living with or pub/2010progressreport/report/en/index.html

affected by HIV in Eldoret, Thika and Nakuru. The 6th International Conference on HIV
project will provide integrated HIV and SHR services UNAIDS report on the Treatment and Prevention
and mentorship training to support young people in global AIDS epidemic 2010 Adherence
issues beyond the health sector. Based on the latest data from 182 countries, this Date: 22-24 May 2011
report provides comprehensive analysis on the Location: Miami, Florida, USA
AIDS epidemic and response, and includes new UNAIDS REPORT ON THE
GLOBAL AIDS EPIDEMIC | 2010
Website: http://www.iapac.org
country by country scorecards on key issues facing 20th World Congress for Sexual
the AIDS response. Health
A fully searchable website containing more than Available at: http://www.unaids.org/globalreport/default.htm Date: 12-16 June 2011
70 advocacy and programmatic resources on Location: Glasgow, Scotland
linking sexual and reproductive health and HIV, Website: http://www.kenes.com/
compiled by experts in linkages at the policy, was
programme and service delivery levels.
http://www.srhhivlinkages.org/

HIV team contact details

Kevin Osborne Senior HIV Advisor kosborne@ippf.org International Planned
Ale Trossero Senior HIV Officer: Linking SRH and HIV atrossero@ippf.org Parenthood Federation
Jon Hopkins HIV Officer: Youth jhopkins@ippf.org 4 Newhams Row, London SE1 3UZ
Dieneke ter Huurne HIV Officer: Prevention, Treatment and Care dthuurne@ippf.org United Kingdom
Daniel McCartney HIV Officer: Research and Technical Support dmccartney@ippf.org tel +44 (0) 20 7939 8200
Lucy Stackpool-Moore HIV Officer: Stigma lstackpoolmoore@ippf.org email HIVinfo@ippf.org
Liz Tremlett HIV Officer: Stigma ltremlett@ippf.org web www.ippf.org