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      The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead

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          Abstract

          According to Joint United Nations Programme on HIV/AIDS (UNAIDS) data, 1,900,000 adults and children were living with HIV in Latin America and the Caribbean in 2018 1, where overall prevalence was 0.5%. Latin America's HIV epidemic is concentrated among men who have sex with men, transgender women, sex workers and people who inject drugs 2. In comparison, the Caribbean has a smaller population of people living with HIV (PLHIV), but a generalized epidemic with an overall HIV prevalence of 1.2% and women accounting for half of all infections 3. Within a short time span and through extraordinary efforts, programmes for universal access to antiretroviral therapy (ART) were rolled out in all countries in the region 4 despite the absence of previous infrastructure for HIV care provision and the lack of international financial support for these programmes in most of the countries. From 2003 to 2008, the number of people on ART doubled and steadily increased afterwards; by 2017, approximately 1.2 million PLHIV (61%) were receiving ART, lagging only after high‐income countries (78%) 1. Furthermore, mortality after ART initiation has decreased and is very similar to that among Latinos receiving HIV care in the USA 5, 6, 7. Regarding prevention, mother‐to‐child transmission (MTCT) has substantially decreased as provision of ART has ramped up 8. And in the past decade, concerted efforts by activists, advocates, committed politicians, scientists and many others, have slowly advanced the recognition of rights of minorities 9, 10. For example, there has been a substantial increase during this century in the number of countries where same‐sex sexual activity has been de‐penalized, equal rights of marriage and child adoption extended to same‐sex couples, and strong legal protections against discrimination and violence based on sexual orientation or gender identity implemented 11. Nevertheless, these advances are threatened by the recent political and economic backlash throughout the entire American continent, adding to the challenges lying ahead in controlling the HIV epidemic 12, 13. First and foremost, discrimination and violence against sexual minorities, in particular, transgender people, is far from over: Seventy‐eight percent of transgender women reported to have been murdered from 2008 to 2015 worldwide were killed in Latin America 14. Such levels of stigma and discrimination remain significant barriers to protection of even the most basic human rights. Similarly, the estimated 2 million people who inject drugs living in Latin America have been neglected despite being one of the groups with the highest HIV prevalence (7.4%) 15. As a result, there is an almost complete absence of reliable data on access to HIV and harm reduction services, which has made it difficult to design, fund and implement evidence‐based strategies to reduce HIV incidence among people who inject drugs in the region 16. The impact of major trade routes, dynamics of regional consumption and the heterogeneity of constantly changing drug enforcement policies and activities on risk behaviours makes this population a moving target 17. However, punitive laws and practices and the sheer lack of political remain major barriers for drug users to access HIV prevention and treatment services 18. As long as there is a broad social and political consensus that continues to frame drug use and dependence as a criminal law concern, rather than as public health and/or human rights issues, costly, wasteful and ineffective punitive interventions will continue 19. During the 38 years of the HIV/AIDS epidemic, we have learned that it can be fuelled in environments where human rights for vulnerable populations are limited. We have also learned that coercive laws and misguided policies aiming to ban sex work and drug use may actually promote HIV transmission 20. There is no straightforward solution since policies to reduce stigma and discrimination, prevent violence and improve access to harm reduction services must be supported and implemented by the same governments that are currently undermining the already adverse social and political environment in some countries. Organized efforts by international and local civil society organizations supported by progressive governments, intergovernmental agencies and academia might lead to the launch of political pressure initiatives to resist and contain the current adverse political trends. Although the continuum of care in Latin American countries has improved over time 21, 22, none have reached the 90‐90‐90 targets established by UNAIDS (Figure 1). The annual numbers of new infections have barely changed in the past two decades, overall mortality reductions have been heterogeneous and lower than expected 6, and AIDS‐related conditions continue to be the leading causes of death among PLHIV in the region despite achievements in access to ART 1. This might be explained by the persistently high frequency of late HIV diagnosis, which still occurs in almost half of diagnosed adults in Latin America 22, 23. Figure 1 The current status of meeting the 90‐90‐90 targets in Latin America. Sources: UNAIDS data 2019. Bulletin on HIV, AIDS and STis in Argentina, December 2018. Joint United Nations Program for AIDS‐UNAIDS, Institute of Public Health. Registration of the care centers of the Public Assistance Network; Superintendence of Health. Current HIV‐AIDS in Peru. General Di rection of Medicines, Supplies and Drugs (DIGEMID). If we aim to fully achieve the 90‐90‐90 targets to control the HIV epidemic and end it as a public health problem, much more must be done to rapidly reduce the proportion of people unaware of their HIV status. Innovative strategies and tools to increase access to HIV screening tests are urgently needed. Strategies to demedicalize HIV counselling and testing services to make them accessible for hard‐to‐reach vulnerable groups and the implementation of proven self‐testing models will be essential to achieve the target of having 90% of PLHIV being aware of their status – the first 90. This may require legislative and administrative changes in many Latin American countries in addition to increasing funds to allow for scale‐up of testing strategies, immediate linkage and same‐day ART initiation programmes with simplified, integrase inhibitor‐based regimens 24, 25, 26. In terms of prevention, efforts to eliminate MTCT have clearly been insufficient (with the exemption of Cuba and six of the English‐speaking Caribbean nations and territories) 8, 18. Broader improvements in healthcare systems are needed; these include strengthening of prenatal/maternal care services paired with improved access to HIV testing for all pregnant women and coordination with ART programmes to immediately initiate them on ART 9. Countries should build on the experiences in Cuba and the Caribbean to eliminate MTCT. Furthermore, pre‐exposure prophylaxis (PrEP) is unacceptably scarce across the region. Programmes must be rapidly expanded as PrEP has been shown to control HIV transmission in concentrated epidemics elsewhere 27. A multinational implementation project (ImPrEP), funded by Unitaid, national governments and other partners, is ongoing and is providing PrEP services to 7500 vulnerable gay men and transgender women in Brazil, Mexico and Peru with encouraging results, such as high retention and adherence (above 80% and 90% respectively) 28, 29. Nevertheless, successful implementation of large‐scale PrEP programmes urgently needs political commitment, leadership, civil society advocates and the involvement of scientific and academic communities to move them forward. Finally, the consequences of migration for the HIV epidemic in our region have rarely been considered in relation to the implementation of HIV prevention, treatment and care programmes. In addition to long‐established migration patterns 30, recent political conflicts and economic instability in Central America and Venezuela have fostered massive waves of immigration throughout the region. UNAIDS estimated in 2017, only 49% of the 120,000 PLHIV in Venezuela had access to ART and <7% were virally suppressed 31. Alarmingly, none of the blood banks in the country are reported to have supplies to test for HIV. Difficulties in ART acquisition in Venezuela in 2017 culminated in widespread drug shortages in 2018 32. As a result, nearly nine of the 10 PLHIV in Venezuela stopped receiving ART and some of them migrated to other countries in search of treatment 31. This could present one of the more dramatic examples on how migration significantly impacts HIV care and control programmes; however, beyond the ongoing crisis, Latin America has historically been the origin, destination and transit of regional migrants. Around 40 million Latin Americans live outside their native countries. Up to half of this population might have migrated within the region, and migrants constantly cross boundaries within the region 33, 34, 35. Large‐scale migration across borders increases vulnerability to HIV/AIDS and other sexually transmitted infections, probably through mechanisms that include sexual exploitation during human trafficking, exposure to sexual violence and new sexual partners, different social and sexual norms and different HIV prevalence rates 36. Moreover the continuity of ART provision for individuals is threatened during migration. Innovative solutions to this situation go beyond any single nation and will require a coordinated plan to ensure that people migrating across borders have their fundamental human right to health guaranteed. Health systems in countries receiving migrants from Venezuela and elsewhere, especially those of Argentina, Chile, Colombia, Mexico and Peru, should be strengthened so that healthcare needs of migrants and refugees can be met without negative consequences for local HIV programmes 37. A regional leadership and collaboration, internationally funded, could assist and support migrants and provide or coordinate services, including healthcare, across borders, building on the previous experiences and leadership of UNICEF and the UN International Organization for Migration. In the past, the diversity of the HIV epidemic in Latin America has been tackled by progressive and often innovative treatment and prevention approaches, together with intense community engagement. This has succeed in spite of the challenges posed by conservative groups and governments, migration, natural disasters and civil unrest. However, our current situation has changed, with new governments, either ideologically motivated or in response to economic crises, reducing public health budgets and seeking to suppress hard‐won liberties and rights. While we can look back at how much we have accomplished and learn from our history and from each other, our epidemic demands a renewed effort, one that integrates new tools at our disposal and follows a clear path built by science, with the strength of will of those who lived with HIV and AIDS in the past. Competing interests All authors confirm that they have no conflicts of interest. Authors' contributions BCR, PFBZ and CC developed the conceptualization and design of the viewpoint and wrote the manuscript. OS, AP and BG contributed to conception, design and reviewing of the manuscript. MM, JSM and PC contributed to design and reviewing of the manuscript. All authors have read and approved the final manuscript.

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          Most cited references18

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          HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.

          Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs. We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes. By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per IDU per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1 needle-syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per IDU per month, there were eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received ART per 100 HIV-positive IDUs. Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population. UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council. Copyright 2010 Elsevier Ltd. All rights reserved.
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            A universal testing and treatment intervention to improve HIV control: One-year results from intervention communities in Zambia in the HPTN 071 (PopART) cluster-randomised trial

            Background The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets require that, by 2020, 90% of those living with HIV know their status, 90% of known HIV-positive individuals receive sustained antiretroviral therapy (ART), and 90% of individuals on ART have durable viral suppression. The HPTN 071 (PopART) trial is measuring the impact of a universal testing and treatment intervention on population-level HIV incidence in 21 urban communities in Zambia and South Africa. We report observational data from four communities in Zambia to assess progress towards the UNAIDS targets after 1 y of the PopART intervention. Methods and findings The PopART intervention comprises annual rounds of home-based HIV testing delivered by community HIV-care providers (CHiPs) who also support linkage to care, ART retention, and other services. Data from four communities in Zambia receiving the full intervention (including immediate ART for all individuals with HIV) were used to determine proportions of participants who knew their HIV status after the CHiP visit; proportions linking to care and initiating ART following referral; and overall proportions of HIV-infected individuals who knew their status (first 90 target) and the proportion of these on ART (second 90 target), pre- and post-intervention. We are not able to assess progress towards the third 90 target at this stage of the study. Overall, 121,130 adults (59,283 men and 61,847 women) were enumerated in 46,714 households during the first annual round (December 2013 to June 2015). Of the 45,399 (77%) men and 55,703 (90%) women consenting to the intervention, 80% of men and 85% of women knew their HIV status after the CHiP visit. Of 6,197 HIV-positive adults referred by CHiPs, 42% (95% CI: 40%–43%) initiated ART within 6 mo and 53% (95% CI: 52%–55%) within 12 mo. In the entire population, the estimated proportion of HIV-positive adults who knew their status increased from 52% to 78% for men and from 56% to 87% for women. The estimated proportion of known HIV-positive individuals on ART increased overall from 54% after the CHiP visit to 74% by the end of the round for men and from 53% to 73% for women. The estimated overall proportion of HIV-positive adults on ART, irrespective of whether they knew their status, increased from 44% to 61%, compared with the 81% target (the product of the first two 90 targets). Coverage was lower among young men and women than in older age groups. The main limitation of the study was the need for assumptions concerning knowledge of HIV status and ART coverage among adults not consenting to the intervention or HIV testing, although our conclusions were robust in sensitivity analyses. Conclusions In this analysis, acceptance of HIV testing among those consenting to the intervention was high, although linkage to care and ART initiation took longer than expected. Knowledge of HIV-positive status increased steeply after 1 y, almost attaining the first 90 target in women and approaching it in men. The second 90 target was more challenging, with approximately three-quarters of known HIV-positive individuals on ART by the end of the annual round. Achieving higher test uptake in men and more rapid linkage to care will be key objectives during the second annual round of the intervention. Trial registration ClinicalTrials.gov NCT01900977
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              Mortality and loss to follow-up among HIV-infected persons on long-term antiretroviral therapy in Latin America and the Caribbean

              Introduction Long-term survival of HIV patients after initiating highly active antiretroviral therapy (ART) has not been sufficiently described in Latin America and the Caribbean, as compared to other regions. The aim of this study was to describe the incidence of mortality, loss to follow-up (LTFU) and associated risk factors for patients enrolled in the Caribbean, Central and South America Network (CCASAnet). Methods We assessed time from ART initiation (baseline) to death or LTFU between 2000 and 2014 among ART-naïve adults (≥18 years) from sites in seven countries included in CCASAnet: Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru. Kaplan-Meier techniques were used to estimate the probability of mortality over time. Risk factors for death were assessed using Cox regression models stratified by site and adjusted for sex, baseline age, nadir pre-ART CD4 count, calendar year of ART initiation, clinical AIDS at baseline and type of ART regimen. Results A total of 16,996 ART initiators were followed for a median of 3.5 years (interquartile range (IQR): 1.6–6.2). The median age at ART initiation was 36 years (IQR: 30–44), subjects were predominantly male (63%), median CD4 count was 156 cells/µL (IQR: 60–251) and 26% of subjects had clinical AIDS prior to starting ART. Initial ART regimens were predominantly non-nucleoside reverse transcriptase inhibitor based (86%). The cumulative incidence of LTFU five years after ART initiation was 18.2% (95% confidence interval (CI) 17.5–18.8%). A total of 1582 (9.3%) subjects died; the estimated probability of death one, three and five years after ART initiation was 5.4, 8.3 and 10.3%, respectively. The estimated five-year mortality probability varied substantially across sites, from 3.5 to 14.0%. Risk factors for death were clinical AIDS at baseline (adjusted hazard ratio (HR)=1.65 (95% CI 1.47–1.87); p<0.001), lower baseline CD4 (HR=1.95 (95% CI 1.63–2.32) for 50 vs. 350 cells/µL; p<0.001) and older age (HR=1.47 (95% CI 1.29–1.69) for 50 vs. 30 years at ART initiation; p<0.001). Conclusions In this large, long-term study of mortality among HIV-positive adults initiating ART in Latin America and the Caribbean, overall estimates of mortality were heterogeneous, generally falling between those reported in high-income countries and sub-Saharan Africa.
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                Author and article information

                Contributors
                brenda.crabtree@infecto.mx
                Journal
                J Int AIDS Soc
                J Int AIDS Soc
                10.1002/(ISSN)1758-2652
                JIA2
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                1758-2652
                01 March 2020
                March 2020
                : 23
                : 3 ( doiID: 10.1002/jia2.v23.3 )
                : e25468
                Affiliations
                [ 1 ] Departamento de Infectología Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán Tlalpan Mexico
                [ 2 ] Fundación Arriarán University of Chile Santiago Chile
                [ 3 ] Taller Venezolano de VIH Caracas Venezuela
                [ 4 ] Fundación Huésped Investigaciones Clínicas Buenos Aires Argentina
                [ 5 ] Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College London London UK
                [ 6 ] Instituto Nacional de Infectologia Evandro Chagas Fundacao Oswaldo Cruz Rio de Janeiro Brazil
                Author notes
                [*] [* ] Corresponding author: Brenda Crabtree Ramírez, Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, C.P. 14080, Mexico. Tel: +52 5554870900, ext. 5504, 5508 ( brenda.crabtree@ 123456infecto.mx )

                [†]

                These authors have contributed equally to this work.

                Author information
                https://orcid.org/0000-0002-2587-1123
                https://orcid.org/0000-0003-4775-4734
                https://orcid.org/0000-0002-4091-5323
                Article
                JIA225468
                10.1002/jia2.25468
                7049674
                32115884
                69a8f3c9-0875-4139-ba27-570f30ecee8e
                © 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 04 October 2019
                : 02 February 2020
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                Figures: 1, Tables: 0, Pages: 4, Words: 3208
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                March 2020
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                Infectious disease & Microbiology
                latin america,hiv epidemic,migration,hiv,prep in latin america,art,hiv testing

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