HIV drug resistance: World Antimicrobial Awareness Week 2020

Over the past decade, the world has witnessed unprecedented scale-up of antiretroviral therapy, which has saved the lives of tens of millions of people. An increased use of HIV medicines has been accompanied by the emergence of HIV drug resistance, which has also steadily increased in recent years.

<p><span style="background-color:transparent;font-size:25px;font-weight:700;text-align:inherit;white-space:inherit;word-spacing:normal;caret-color:auto;">Key definitions</span></p><p><strong>Antimicrobial resistance</strong> occurs when microorganisms resist the effects of medications, making infections harder to treat and increasing the risk of disease spread, severe illness and death. Combatting antimicrobial resistance is a global
priority that needs coordinated action across all government sectors and levels of society. </p><p><strong>HIV drug resistance</strong> is caused by changes in the genetic structure of HIV that affects the ability of drugs to block the replication of the virus. Minimizing the emergence and transmission of HIV drug resistance is a vital part of global
efforts to address antimicrobial resistance.</p><hr /><p><span style="background-color:transparent;font-size:25px;font-weight:700;text-align:inherit;white-space:inherit;word-spacing:normal;caret-color:auto;">Department information note</span></p><p>Over the past decade, the world has witnessed unprecedented scale-up of antiretroviral therapy (ART), which has saved the lives of tens of millions of people. As of December 2019, 25.4 million people out of an estimated 38 million people living with HIV
were receiving ART globally. An increased use of HIV medicines has been accompanied by the emergence of HIV drug resistance, which has also steadily increased in recent years.&nbsp;</p><p>If not prevented, resistance can jeopardize the efficacy of antiretroviral drugs, as shown by a newly published <a href="https://pubmed.ncbi.nlm.nih.gov/33202025/" target="_blank">systematic review and meta-analysis</a>. Resistance is also associated with an increased number of HIV infections and HIV-associated cases and
deaths.
<br /></p><p>To coordinate the global effort to protect the long-term efficacy of HIV medicines, WHO, in collaboration with HIVResNet, a global HIV resistance network, developed an <a target="_blank" href="https://www.who.int/publications-detail-redirect/978-92-4-151009-7">HIV drug resistance prevention and assessment strategy</a>. The strategy provides an overview of WHO-recommended
actions at the country level to combat unnecessary emergence and transmission of drug-resistant HIV.
</p><p>The 2020 updated HIV drug resistance strategy &ndash; which is to be released before the end of the year – considers lessons learned in the field over the last decade and anticipates the ongoing scale-up of antiretroviral therapy and HIV pre-exposure
prophylaxis in low- and middle-income countries during an era of transition to dolutegravir-based regimens.</p><p>The foundation of WHO&rsquo;s recommendation is the development, by countries, of a 5-year <strong>national action plan on HIV drug resistance</strong>, which is aligned with the 5 key pillars of the <a target="_blank" href="https://www.who.int/publications-detail-redirect/978-92-4-151284-8">Global action plan on HIV drug resistance</a>: </p><ol><li>prevention and response, </li><li>monitoring and surveillance, </li><li>research and innovation, </li><li>laboratory capacity, and </li><li>governance and enabling mechanisms. </li></ol><p>The Global HIV Drug Resistance Global Action plan mirrors and is interlinked with the <a target="_blank" href="https://www.who.int/publications-detail-redirect/9789241509763">Global action plan on antimicrobial resistance</a>.&nbsp;&nbsp;</p><p>Standardized<strong> surveillance of HIV drug resistance</strong> provides countries with actionable evidence that is used to optimize patient and population-level treatment outcomes. The surveillance of<strong> pretreatment HIV drug resistance</strong> (drug resistance present in the virus of people starting or re-starting antiretroviral therapy) informs the national choice of recommended first-line antiretroviral regimens. WHO has developed survey methods to monitor pretreatment HIV drug resistance
among <a href="https://www.who.int/publications-detail-redirect/9789241507196">adults </a>and
<a href="https://www.who.int/publications-detail-redirect/9789241512541">infants</a>.&nbsp;&nbsp;</p><p>WHO has just released the guidance on<a href="https://www.who.int/publications-detail-redirect/9789240009813"> HIV drug resistance surveillance in countries scaling up pre-exposure prophylaxis (PrEP)</a>.
While it is universally expected that HIV infection will be an infrequent event among populations taking pre-exposure prophylaxis to prevent HIV infection, drug-resistant HIV can emerge in the very small number of people who may become infected while
taking PrEP. This can negatively impact the effectiveness of available antiretroviral treatment options due to the use of the same drugs for both prevention and as components of recommended first-line antiretroviral therapy.</p><p>Countries implementing HIV drug resistance surveys are encouraged to perform HIV drug resistance testing at laboratories designated by WHO for the purpose of performing HIV drug resistance testing for surveillance. </p><h3>Map: WHO HIV drug resistance laboratory network</h3><p><a href="https://www.who.int/images/default-source/departments/hiv/hivdr1-v3-who-hiv-drug-resistance-laboratory-network-nov2020.png?sfvrsn=b853b181_0"><img sf-custom-thumbnail="true" src="https://www.who.int/images/default-source/departments/hiv/hivdr1-v3-who-hiv-drug-resistance-laboratory-network-nov2020.png?sfvrsn=b853b181_0" sf-constrain-proportions="true" width="800" alt="WHO HIV drug resistance laboratory network" sf-size="926277" /></a></p><p>These laboratories are members of the WHO HIVResNet and function under the <a href="https://www.who.int/publications-detail-redirect/978-92-4-000987-5"> WHO HIV drug resistance Laboratory Operational Framework</a>.
This second edition,&nbsp;just published in 2020, reflects recent technical and strategic developments, including consideration of next-generation sequencing methods, updates to standard operating procedures and quality assurance of HIV sequences
such as the integrase gene and assay validation recommendations. The recommended specimen types for HIV drug resistance genotyping are plasma or dried blood spots. Dried blood spots should be used for HIV drug resistance surveys in which plasma cannot
be handled as per WHO recommendations. The <a href="https://www.who.int/publications-detail-redirect/9789240009424">WHO manual for HIV drug resistance testing using dried blood spot specimens</a>,
third edition&nbsp; just published in 2020, emphasises best practices for dried blood spots preparation, storage and shipping, as well as selection of appropriate positive controls.&nbsp;</p><p>WHO&rsquo;s <a href="https://www.who.int/publications-detail-redirect/WHO-CDS-HIV-19.21">HIV drug resistance report 2019</a> showed substantial progress in the surveillance of HIV drug resistance. Between 2004 and 2020, 57 countries implemented surveys of HIV drug resistance using WHO-recommended methods (see map below), and 17 countries have plans to conduct surveys. Countries
are strongly encouraged and supported in their efforts to promptly interpret, disseminate and use HIV drug resistance survey data at national and global levels to inform treatment policy choices and to advocate for strong HIVDR prevention and response
efforts.
</p><h3>Map of countries implementing national HIV drug resistance surveys, 2004&ndash;2020</h3><div><a href="https://www.who.int/images/default-source/departments/hiv/hivdr2-implementation-of-national-hiv-drug-resistance-survey-2004-2020.png?sfvrsn=a962ef32_4"><img sf-custom-thumbnail="true" src="https://www.who.int/images/default-source/departments/hiv/hivdr2-implementation-of-national-hiv-drug-resistance-survey-2004-2020.png?sfvrsn=a962ef32_4" sf-constrain-proportions="true" width="800" alt="Implementation of national HIV drug resistance surveys, 2004–2020" sf-size="911400" /></a></div><p>&nbsp;</p><h2><hr />Webinar&nbsp;</h2><p>Join&nbsp; us for a webinar on "<a href="https://www.who.int/news-room/events/detail/2020/11/20/default-calendar/webinar-addressing-hiv-drug-resistance-to-protect-the-effectiveness-of-hiv-treatment">Addressing HIV drug resistance to protect the effectiveness of HIV treatment</a> in celebration of World Antimicrobial Awareness Week 2020 on 20 November from 14:00 to 15:30 CET (Amsterdam, Berlin, Rome, Stockholm, Vienna time)</p><p>The webinar will cover WHO&rsquo;s strategy to monitor and response to HIV drug resistance, latest global epidemiological data, new surveillance methods, and most recent data on resistance to new ARV medicines used for HIV treatment and prophylaxis.</p>

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Regulating sanitation services as a public good

Kam Nov 19 , 2020
<p>Yvonne Magawa (ESAWAS), Batsirai Majuru (WHO), Bisi Agberemi (UNICEF), Jan-Willem Rosenboom </p><p>& Alyse Schrecongost (BMGF)</p><p><img src="https://www.who.int/images/default-source/departments/wash/sanitation-workers-sos-report-2147692ee0afd4eec85820afa956f3952.jpg?sfvrsn=377ebb9c_5" alt="Two sanitation workers"></p><h6><em>Faecal sludge transport workers in Kenya - UNICEF/UN0348903/Modola</em></h6><p><em>This blog is part of a series for World Toilet Day highlighting issues within the </em><a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health"><em>WHO-UNICEF State of the World</em><em>’</em><em>s Sanitation</em></a><em> report.  The topic of sanitation regulation is also covered in '</em><a href="https://iwa-network.org/news/catalysing-citywide-sanitation-for-all-through-regulating-service-providers"><em>Catalysing Citywide Sanitation For All Through Regulating Service </em></a><a href="https://iwa-network.org/news/catalysing-citywide-sanitation-for-all-through-regulating-service-providers"><em>Providers</em></a><em>' by </em><a href="https://iwa-network.org/projects/regulating-for-citywide-inclusive-sanitation/"><em>IWA's Regulation for Citywide Inclusive Sanitation initiative's</em></a><em> advisory and taskforce members - Yvonne Magawa (ESAWAS), Diego Polania (CRA), and Gustavo Saltiel (World Bank).</em></p><p>For too long sanitation, specifically on-site sanitation systems such as septic tanks and pit latrines, have been left in the realm of household responsibility.</p><p>The scant investments available for urban sanitation gravitate towards sewered infrastructure, reaching small proportions of large urban areas, primarily wealthier populations.  Urban populations continue to grow rapidly, often in dense settlements with limited basic public services or infrastructure.  Particularly for sanitation, households are forced to make do, covering the costs of basic access for themselves.  The very nature of safe sanitation, however, means that the decisions and priorities of individuals are largely decoupled from what would be required to protect public health, the environment, and reach the poorest. Services for safely containing, emptying, transporting and treating human waste, and preventing pits and septic tanks from contaminating groundwater and open drains are needed, but without regulation, investments will not prioritize public health outcomes. </p><p>This situation is both unfair to the households and ineffective in achieving a primary purpose of sanitation: protecting public health.  Sanitation is fundamentally a public good.  Individuals’ decisions maximize their own best interest – they do not necessarily serve the best interests of society at large. </p><p>Investments in sanitation need to be planned, regulated and financed to align the priorities of individual households with those of service providers.  This alignment is required to address the broader social goals of public health protection, cleaner environments, and stronger economies.  Among the countries that have made extraordinary gains in a generation, a common factor among them has been strong political leadership that clarified public goals, gave clear mandates<a href="https://bmgf.sharepoint.com/teams/wsh/USM/Bodies%20of%20Work/CWIS/CWIS/WTD%20sanitation%20reguation%20BMGF%20ESAWAS%20WHO_draft_v2_AMS.docx#_msocom_5"> </a>to the responsible authorities to achieve those goals, regulated authorities’ delivery of services, and mobilized the corresponding investments needed.</p><p>Where utilities manage sewers, generally those utilities have a defined, public service-oriented mandate, performance accountability, and financing strategies.  Over two thirds of countries have environmental standards for wastewater treatment. </p><p>Beyond sewered areas, urban sanitation remains a public good, but it is largely delivered by unorganized and unregulated private or informal actors.  Few countries have standards for faecal sludge treatment or safe reuse of wastewater or sludge.  Individual providers of emptying and transport services may or may not be subject to a smattering of on-paper regulatory codes or standards.  Where standards exist, they are almost universally decoupled from efforts to monitor, incentivize or enforce compliance.  As a result, less than a third of mandated oversight agencies are able to carry out the basic functions of monitoring and enforcement. </p><p>Robust regulatory systems can address the market failures of urban sanitation to protect public health and incentivize delivery of safe, inclusive, and viable services.  We highlight three issues critical to pursuit of this outcome that merit case studies, discussion, and sector learning and evolution. </p><p>First, <strong>regulations can help to better link sanitation services to public health protections.</strong>  Simple statement but not a simple task. Regulation of sanitation services has long lagged behind that of water services: only 1 in 5 countries have any indicators for sanitation service quality.  If sanitation services are to protect public health, then public health-aligned guidance and oversight must become the expected norm in all countries, for sewered and non-sewered sanitation systems alike.  Health outcomes must be designed into simple, transparent and effective by-laws, codes and standards; actionable and funded monitoring and enforcement systems are required to make those standards meaningful.  To achieve this, systems must be designed in collaboration with public health authorities.  Public health risk assessment and risk management priorities must underpin product and service standards along the full sanitation service chain.  <em>This includes measures to address the specific health risks, stigma and marginalization faced by sanitation workers in unregulated settings. </em></p><p>Second, <strong>as with public health regulation, the focus of economic and performance regulation of sanitation services must be on safe, inclusive services, irrespective of the infrastructure used.</strong>  Failure to focus mandates and regulatory frameworks on service outcomes instead of infrastructure inputs exacerbates systemic inequity and exclusion. In most cases, providers of non-sewered products and services remain unregulated and unorganized retail actors.  They deliver services with wide variability in price and quality, with little accountability for the quality of their service to households or for public health. Market structuring – particularly economic and performance regulation of services – is required if public or private providers are to be incentivized to protect public health, to reach low income communities, and to mobilize investment and innovation.  Economic regulatory tools can help align customer inclusion and affordability goals with providers’ financial interests.</p><p>Finally, <strong>if the public sector is well-structured and regulated, it can increase business opportunity, available finance, and incentivize investment in innovation to meet health and inclusivity goals.</strong>  Recognizing sanitation as a public good does not imply that the public sector has sole responsibility for delivering public services.  Indeed, without structuring sanitation as a public service, opportunities for private sector engagement are more restricted, higher risk, less effective, less profitable, and less aligned with the public good.  Tools and business models that align public, customer, and provider interests have not always been clear, but promising innovations are emerging in urban markets in Kenya, Malaysia, Zambia, and other countries.  In these areas, regulators are insisting on improved sector outcomes.  They are also supporting utilities and the private sector to learn and grow as the sector transforms and more is expected of everyone. </p><p>Significant challenges remain.  In many countries sanitation is entirely managed by municipalities.  Municipal service systems tend to be subject to individuals’ short term political interests, missing accountability mechanisms, and with limited flexibility to generate or ringfence revenue effectively. Treatment compliance or the relationship between customer-based revenue mechanisms and service quality can be opaque.</p><p>We have good reason to believe that well-designed regulatory systems can accelerate global progress toward SDG 6.2 and 6.3, and improve public health.  The <a href="https://www.who.int/publications/i/item/9789241514705">WHO Guidelines on Sanitation and Health</a> provide a useful point of departure in addressing public health criteria in sanitation regulations, and articulating the role of the health sector in sanitation authorities’ service provision.</p><p>In addition, a new publication – the<a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health"> </a><a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health">WHO-UNICEF State of the World</a><a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health">’</a><a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health">s Sanitation</a> – launching today draws attention to the role of regulators in solving the sanitation crisis.  The report brings together lessons from high-achieving countries, and presents a vision of what is needed to deliver universal access to safe sanitation.  It calls for urgent action around five areas: governance; financing; capacity development; data; and innovation, and highlights leadership, effective coordination and regulation as effective pathways for achieving safe sanitation for all.  Building on the directions outlined in the report, WHO and other partners working with regulators’ networks such as the East and Southern Africa Water and Sanitation (<a href="https://www.esawas.org/">ESAWAS</a>) Regulators Association and the WHO International Network of Drinking-water and Sanitation Regulators (<a href="https://www.who.int/teams/environment-climate-change-and-health/water-sanitation-and-health">RegNet</a>), will work to create concrete and contextualized changes in regulation of sanitation services that can inform future updates of the report.</p><div><div><div><p> </p></div></div></div><p> </p><p><em> </em></p><p> </p>