It was the best of times, it was the worst of times

It was the best of times, it was the worst of times (Charles Dickens, 1859, “The Tale of Two Cities”) ...
 
The incremental growth of HIV  science  year by year has accumulated many successes in many areas. This science has lead to a range of interventions, yet  biological efficacy will not be effective without adherence, and adherence is situated in the domains of cultural, economic and gender realities.
 
I have heard today that the issues of adherence in a Washington clinic,  in a Melbourne hospital, in a west African village, or in a Russian prison  demonstrate a  great diversity of challenges. Yet the discourse of human rights has been strengthened as the common  basis for empowering, authorising and allowing  people to be agents for the necessary changes in  these settings.  Though, of course, this does not diminish the difficulties in each setting.
               
A Ugandan colleague, Dr Musoke,  has highlighted the key roles  of political commitment, logistical problems such as stockouts, and the difference between capital city tertiary facilities and rural cities. There are still many difficulties. Concerns about long term resistance are real issues in many settings.
 
There is a move internationally to prioritise the disease burden due to non-communicable diseases (NCD). The NCD agenda is in one sense, I believe, rising to the top of the international health priorities. In this context, there were interesting studies from Uganda (Chamie et al) and from Nigeria (Gwarzo et al) indicating that HIV programs were also effectively integrating screening for non-communicable diseases, and also from Zambia (Mulanga et al) including cervical cancer services.
 
I learnt about the Gardner Treatment cascade which is an important new tool to allow us to picture the cascade of challenges of access and adherence that are now and future concerns. Let me share this example to illustrate how it works. 
For every 100 individuals living with HIV in the United States, it is estimated that:

• 80 are aware of their HIV status.
• 62 have been linked to HIV care.
• 41 stay in HIV care.
• 36 get antiretroviral therapy (ART).
• 28 are able to adhere to their treatment and sustain undetectable viral loads.

In short, CDC estimated that only 28 percent of the more than 1 million individuals in the U.S. who are living with HIV/AIDS are getting the full benefits of the treatment they need to manage their disease and keep the virus under control. Put another way, nearly 3 out of 4 people living with HIV in the U.S. have failed to successfully navigate the treatment cascade. Since a picture “is worth a thousand words,” see the included image.