Entry points to antiretroviral treatment
Scaling up access to antiretroviral (ARV) treatment must build on existing clinical or public health services and extend their coverage. It also means making the most of synergies between prevention and care, recognizing that people are more likely to follow prevention advice when they receive comprehensive services. To accomplish this, it will be necessary to exploit opportunities - or entry points - for identifying people who could benefit from treatment. Entry points must provide, or facilitate the link to, HIV testing and counselling, the gateway to treatment services. Entry points include:
- Clinical situations where there may be a high suspicion of HIV-related disease (acute clinical services; tuberculosis services) or where people seeking care have a high likelihood of HIV infection (sexually transmitted infection or drug treatment services).
- Community-based opportunities for identifying people within high-prevalence networks who are not using clinic services.
Entry points: make sure to…
- go where HIV infection and HIV-related disease is.
- find people who need treatment most.
- reach out to people who do not come to you.
- Strengthen community outreach for testing and counselling services
- Start with tuberculosis (TB) services
- Actively seek patients sick with HIV/AIDS in acute medical clinics and hospital wards
- Work with maternal and child health (MCH) and mother-to-child transmission (MTCT) prevention programmes
- Link sexually transmitted infection (STI) and ART services
- Bring treatment to injecting drug users, sex workers and other vulnerable populations
- Generate demand for HIV counselling and testing and care
Key entry points where HIV-related disease is more likely
Many people using the following services are likely to have HIV-related illness and would benefit from immediate ART.
HIV is fuelling the tuberculosis epidemic in regions with a high prevalence of HIV and is one of the most common causes of morbidity and mortality in HIV-positive adults. In some high-burden countries, more than 70% of TB patients are co-infected with HIV. However, there are still very few TB services that provide appropriate routine HIV counselling and testing services. In many localities the TB services are the best initial entry points to develop, where many patients in immediate need of ART will be found.
Acute medical services (clinic and hospital ward)
In a similar way to TB services, medical clinics (adult and paediatric) and hospital wards have a high proportion of HIV-infected patients. Many high-burden countries report bed-occupancy rates in excess of 50% related to HIV. Childrens’ nutrition and re-feeding wards are similarly challenged by HIV. Medical facilities are thus an important entry point for ART services, and urgent implementation of routine counselling and testing services as the standard of care is critical in any attempt to scale-up in line with 3 by 5 target.
Many countries have home-based care services, often run by nongovernmental organizations (NGOs), community-based organizations (CBOs) and faithbased organizations (FBOs). Usually home-based care is focused on chronically sick, debilitated individuals known to be infected with HIV, and should be an important entry point to ART programmes. Rather than focusing on counselling and testing, this entry point needs to speed up the ways that individuals in the programme can be clinically evaluated for immediate commencement of ART. It is likely that with HBC services, the majority will urgently need to start ART.
Key entry points where asymptomatic HIV infection is more likely
A general issue for these entry points is that, once identified, the HIV-infected individual is less likely to need immediate referral to, or enter into an ART programme. The more pressing issue is to set up a system for regular assessment of the clinical status of those infected; or to refer individuals to a setting where periodic evaluation can be conducted.
MCH clinics and MTCT prevention programmes
Many MCH services now implement MTCT prevention services or offer HIV testing and counselling. While enhancing the prevention of HIV infection in infants, HIV-related care and treatment need to be extended to HIV-infected women and their families. This is an obvious entry point therefore for ART programmes. To effect this, clinical screening of women for signs of HIV-related disease need to be included, to compliment the provision of testing and counselling and ARVs for prevention of mother-to-child transmission.
Link STI and HIV services
STIs facilitate the spread of HIV and serve as a marker for infection. Services providing STI care should routinely offer testing and counselling to ensure that STI patients can find out their HIV status and be evaluated for treatment; and informed about clinics where they can regularly be reviewed for disease progression.
- Scale up testing and counselling services within STI services, including private-sector providers.
- Train health care providers working in services providing STI care to clinically screen better identify and refer persons who might be eligible for antiretroviral treatment.
- Emphasize the provision of youth-friendly services that promote STI symptom recognition and awareness of HIV status.
- Use simple clinical protocols and strengthen capacity of health care workers providing STI services.
Bringing treatment to drug users
In some regions, injecting drug users (IDUs) comprise a significant proportion of infected persons. While the majority may initially be asymptomatic, almost all will eventually require antiretroviral treatment.
- Increase access to both voluntary and health-service-provider-initiated testing and counselling in drugdependence treatment and harm-reduction facilities with referral linkages.
- Establish substance-dependence treatment (including drug substitution) in ART clinics to help stabilize IDUs and improve compliance with treatment.
- Deliver ART through drug dependence treatment services.
Reaching out to other vulnerable groups
Many people who need HIV prevention, care and treatment are beyond the reach of health-care services. Poverty, migration, civil unrest, stigma and discrimination are among factors that marginalize people, increase their vulnerability to infection and reduce their access to services. The combined hazards of vulnerability and poor access are often most acute among young people. In order to increase access and uptake of integrated HIV services, ‘active’ entry points are needed to reach out to marginalized populations that do not seek treatment on their own.
- Integrate existing prevention services for sex workers, men who have sex with men and others with testing and counselling, care and treatment.
- Work with especially vulnerable young people (e.g. out-of-school, slum-dwelling adolescents) through peer networks and youth-friendly health services.
- Work with employers, unions, social services, NGOs, CBOs and FBOs to extend prevention and treatment services to transport and itinerant workers who may be particularly vulnerable and in need of treatment.