Introductory Chapter: Future Opportunities and Tools for Emerging Challenges for HIV/AIDS Control

1. Introduction

It is almost 40 years since the first cases of HIV/AIDS were identified. The disease was a tragedy of monumental dimensions. Millions have died leaving families helpless especially in developing countries. Experiences of unprecedented suffering and social disruption prevailed in the early part of the pandemic. Orphans became heads of households and carried the family burden as the disease killed both parents. Gradually over time, some feelings of hope emerged following the launch of the UN Global Strategy for Prevention and Control of HIV/AIDS. Steady progress was made in prevention and management of persons living with HIIV/AIDS. Anti-retroviral treatment offered the best hope for the patients. The quality of life for people living with HIV/AIDS steadily improved on with anti-retroviral treatment. Mortality has reduced and AIDS is no longer a death sentence, but a chronic disease. Longevity too for them has improved significantly since the introduction of Anti-Retroviral Therapy in 2003. Opportunistic Infections, the major causes of death too have declined. New infections and HIV-related mortally is declining worldwide [1, 2]. The UNAIDS global HIV/AIDS program [3] based on combination strategy for risk reduction targeting sexual behavior has successfully reversed trends in new infections. The current UNAIDS Global Strategy targets elimination of infection by 2030 by focusing more on reducing inequities hindering progress, enhancing people-centered services, and removing legal and social constraints that hamper human rights. The overall goal of the strategy is based on human rights, gender equity free of discrimination. The strategy prioritizes the elimination of HIV infection particularly among children. The new strategy priorities the interventions for the prevention of mother to child transmission with a target of elimination of mother-to-child transmission. Reviews on the evolution of the disease are helpful in realizing missed opportunities to help in the future outbreaks.

2. Challenges in behavior change

Behavior change for safe sexual practices is essential in mitigation of spread of infection. The key components of the these safe sexual practices include abstinence, fidelity, and condom use and have been vital to HIV prevention [4]. Messages need to be targeted using more accurate, rational, and evidence-based interventions. However, poor surveillance systems for both case reporting and behavioral surveillance remains weak especially where HIV burden is greatest. Furthermore, stigma and societal issues persist, which are barriers that have partly promoted perceived low risk among the communities [5]. There are instances where intensified implementation of the combination interventions on key populations within the context of the highest-risk scenarios and targeting local HIV epidemiology has yielded good results. Such outstanding examples ought to be shared as we approach the last mile in our containment efforts. Targeting of appropriate packaged messages has worked in some communities, the experience of which could be benchmarked toward the elimination of infection.

Other new behavioral and societal challenges have emerged in some instances. For instance, prevention messages on risk reduction are being undermined by the successes following effective and successful anti-retroviral treatment. Complacency among the general public especially the youth is gradually growing. The youth do not see the disease as a threat encouraged by the absence of the earliest typical clinical features of extreme body wasting associated with high fever and diarrhea [6]. Special interventions including condoms are to be scaled up for key populations. The high prevalence of discordancy of infection among couples in committed relationships needs to be addressed. Instead of focusing on individuals, programs should aim at couples as an entity since the risks are similar so as to maintain the discordancy in stable relationships.

Behavior and mental health are often linked. However, this relationship is often missed when planning for prevention strategies and behavior change. Sexual compulsivity and hyperactivity, for instance, are rarely considered yet it is a mental behavioral deficit that needs attention in some communities. This trait may be associated with high risk and addressing it could have some impact in reduction of HIV transmission. Mental health should be integrated into the next programs for the elimination of infection.

3. The test and treat policy

The test and treat policy is regarded as an effective way to reduce infections because undetectable viral load translates into no transmission in most circumstances. This approach should significantly support the elimination of infection. The UNAIDS global 90–90–90 strategy for the elimination of the scourge by 2030 is being implemented worldwide, but with varying levels of success. This strategy is based on test and treat policy and the sustenance of quality undetectable viral loads. For such intervention to be effective, the tests need to be accessible. Equally important for the client is that access is user-friendly. While the classifications of tests from first generation to fourth generation is well described for appropriate usage, the limited financial environment presents challenges for optimal work and calls for rational more appropriate tools. For instance, the challenges of screening and detection during the acute and the window period post infection should be examined to enhance accuracy and appropriateness. The tests should be rapid and of high quality. Such tests are most appropriate in low resource settings where costs and convenience remain a major consideration. This challenge is most pronounced in low-income countries. While early testing and diagnosis are key to achieving zero new infections, universal access to testing and treatment remains a herculean task. In Sub-Saharan Africa, for instance, testing is not optimal due to weak health systems and costs. Other impediments may include deterioration of clinical status or death of a partner. In local settings this can significantly impact on uptake [5]. Some countries have coped with this by the expansion of primary health care through community engagements strategy and effort.

4. Challenges in perinatal diagnosis and care

Perinatal care and management of mother and baby need clear guidelines. Perinatal diagnosis preceding management in particular remains a challenge. For instance, the guidelines for the management of perinatal transmission in neonates remain unclear. This is primarily due to the administration of Anti-retroviral Therapy to pregnant mothers and her child after delivery. Thus, the identification and management of HIV infection among neonates during the perinatal period are yet to be made clearer. Thus, there is a paucity of evidence for the rationale management of HIV-infected neonates. The discussion should be made on the implications and barriers for treatment guidelines for successful outcomes for neonates and should be examined for the better management of these cases.

Overall some laboratory functions and parameters functions are yet to be clarified. For instance, the role of platelet parameters and pathophysiology is not fully understood in the managing people living with HIV/AIDS. There should therefore be increasing attention on platelet functions among this group because of reported cardiovascular severe adverse effects and thrombosis and related conditions [7]. More studies and evidence are required to improve care and social well-being.

5. Responding to challenges for the elderly

The elderly living with HIV/AIDS will increase with improved anti-retroviral treatment. A resurgence of noncommunicable diseases is bound to grow. Diabetes and hypertension usually associated with obesity will present special challenges during this life extension. Additional social programs will be needed to provide amenities for the elderly. They will need support to promote social inclusion and gainful integration in order to participate in community and societal agendas. Frameworks for housing, jobs, and direct financial support are challenges to consider during the HIV/AIDS long-term recovery.

The book chapters in the proposed updates will examine and discuss arguments on these crucial issues, the consideration of which could be the recipe for the improvement of strategies for the elimination of HIV/AIDS by 2030 and wellness for all.