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Expanding HIV testing and the use of ARVs for treatment and prevention Getting to 15 million by 2015… and thinking beyond Gottfried Hirnschall MD, MPH.

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Presentation on theme: "Expanding HIV testing and the use of ARVs for treatment and prevention Getting to 15 million by 2015… and thinking beyond Gottfried Hirnschall MD, MPH."— Presentation transcript:

1 Expanding HIV testing and the use of ARVs for treatment and prevention Getting to 15 million by 2015… and thinking beyond Gottfried Hirnschall MD, MPH Department of HIV/AIDS, World Health Organization July 26, 2012

2 Questions for today Can we reach 15 million by 2015? Is 15 million enough to achieve optimal impact on treatment and prevention? What strategic choices can be made? What are the opportunities to enhance ART program effectiveness and reach?

3 8 million on ART by end 2011 …15 million is achievable ! 8 million 15 million

4 8 million on ART by end 2011 …15 million is achievable ! 8 million 15 million

5 ART scale-up: three success stories High-level commitment and resources Proactive approaches to HIV testing Innovation in service delivery Integration Task-shifting Community-based services ART coverage

6 Disparities in ART coverage between regions and populations ART coverage * 2010 HIV case reporting (18 countries)

7 Scale-up of ART, number of AIDS deaths and new HIV infections in LMIC*, 2001–2011 * LMIC = Low- and middle-income countries

8 Effect of ART coverage on rate of new HIV infections in a rural South African population Source: Tanser F et al. CROI 2012 For every 10% increase in coverage there is a 17% decrease in individual risk

9 Effect of ART coverage on rate of new HIV infections in a rural South African population Source: Tanser F et al. CROI 2012 For every 10% increase in coverage there is a 17% decrease in individual risk

10 Balance of evidence favours earlier initiation of ART ↓ Drug toxicity ↓ Resistance ↓ Upfront costs Preservation of Tx options ↑ Clinical benefits (AIDS- and non-AIDS related) ↓ HIV and TB transmission ↑ Potency, durability, tolerability ↑ Treatment sequencing options ↑ Medium/long-term cost savings Delayed ART Earlier ART

11 Relationship between transmitted resistance to NNRTI drugs and ART coverage in LMIC Source: HIV drug resistance report, WHO, 2012

12 ART eligibility: 5 policy scenarios Recommended Since 2003 CD4 ≤ 200 Recommended since 2010 Recommended since 2010 CD4 ≤ 350 Incremental approach 2012 CD4 ≤ TasP Ongoing systematic review of evidence (GRADE review) Ongoing systematic review of evidence (GRADE review) CD4 ≤ 500 “Test and treat” All HIV+ ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM) ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM) Estimated millions of people eligible for ART in LMIC in Estimated millions of people eligible for ART in LMIC in

13 ART eligibility: 5 policy scenarios Recommended Since 2003 CD4 ≤ 200 Recommended since 2010 Recommended since 2010 CD4 ≤ 350 Incremental approach 2012 CD4 ≤ TasP Ongoing systematic review of evidence (GRADE review) Ongoing systematic review of evidence (GRADE review) CD4 ≤ 500 “Test and treat” All HIV+ ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM) ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM) Estimated millions of people eligible for ART in LMIC in Estimated millions of people eligible for ART in LMIC in

14 WHO’s ARV-related guidance in 2012 Treatment as Prevention (TasP) Recommendation for TasP in sero-discordant couples Consider lifelong ART for pregnant women (“B/B+”) Explore use of TasP in key populations (SW, IDU, MSM) Pre-Exposure Prophylaxis (PrEP) Recommendation for demonstration projects in sero-discordant couples and MSM

15 WHO’s consolidated ARV guidelines in 2013 (children, adolescents, adults, pregnant women, key populations) WHAT TO DO? (when to start or switch, how to monitor, which regimen to use, co-morbidities) HOW TO DO IT? (diagnostics, service delivery) HOW TO DECIDE? (scale-up, equity and ethics, M&E) Clinical Programmatic Operational

16 Significant variation in ART eligibility thresholds among countries CD4 count for ART initiation ≤ ≤300 ≤350≤350 + TasP ≤500≤500 + TasP Number of countries Results of a WHO survey (2011, n= 61 countries)

17 17 Low-incomeLower middle- income High-incomeUpper middle- income Year of starting ART Mean CD count (cells/µL) Estimates from random-effects model adjusted for age, sex and year of starting ART, Mean CD4 count at ART initiation is below 200 in LMIC Source: Egger M. CROI

18 HIVDR Early Warning Indicators, 2011 Proportion of clinics achieving WHO-recommended standards Source: Bennett DE et al. CID 2012 Supp 4 pp %

19 The test-treat-retain cascade Pre-ART care and support Pre-ART care and support ART ART eligible HIV+

20 Patient enrolment into HIV care and treatment, six studies in sub-Saharan Africa % Source: Mugglin C et al. IeDEA Southern Africa ( in press) N = 58,779 persons

21 Key areas for optimization in the cascade Expand, simplify and diversify HIV testing Offer concrete interventions in the pre-ART window Use simple and better drugs for first- and second- line Provide diagnostic tests and monitoring tools at point-of-care Innovate service delivery to enhance adherence and retention

22 Provider-initiated testing and counselling (PITC) in Africa  42/53 countries in Africa have PITC policies 1  High PITC acceptance by ANC 2 & TB patients 3,4  Most clinical settings in generalized epidemics not routinely offering HIV testing 5 1 Baggaley (2012) Bulletin WHO, 2 Etirbet (2004) AIDS Care; Byamugisha (2010) J Int AIDS, 3 WHO, Global TB control (2011), 4 Corneli (2008) IJTBLD, 5 MacPherson (2012) Trop Med. Date not identified Adoption of a policy on PITC Not adopted Data not available

23 Scaling up HIV testing in the community  Home-based (door-to-door)  Community  Index-case  Campaigns plus  HTC-plus –malaria, safe water  Non-communicable diseases  Mobile outreach  General populations  Key populations  Workplaces, schools

24 A potential new approach: self-testing Today  Practiced 'informally' by many health workers 1  Included in Kenyan National Guidelines  Readily available over the internet and in pharmacies in some countries  Approved by FDA in USA this month Future potential  General population?  Marginalized groups?  PrEP? 1 Napierala S, (2011). HIV self-testing among health workers

25 ART optimization approaches Once daily FDC for 1 st line (e.g., TDF/3TC/EFV) Heat stable once-daily boosted PI options for 2 nd line (e.g., ATV/r) Solid pediatric formulations (sprinkles, dispersible tablets) Replacement of regimen components by new drugs/classes (e.g., integrase inhibitors, NRTI pro-drugs, entry blockers) New therapeutic approaches (e.g., induction/maintenance, co-therapies, anti-latency drugs) SHORT TERM Next 1-2 years Improve currently available drugs and formulations SHORT TERM Next 1-2 years Improve currently available drugs and formulations MEDIUM TERM Next 2-5 years Add new drugs/better sequencing MEDIUM TERM Next 2-5 years Add new drugs/better sequencing LONG TERM Next 5-10 years Use new strategies LONG TERM Next 5-10 years Use new strategies

26 ARV drugOptimization methods Present cost in USD (per patient/year) Expected cost in USD (per patient/year) TDF Process chemistry and dose optimization 8763 (  28%) AZT Dose optimization 8960 (  33%) EFV Reformulation and dose optimization 6331 (  51%) ATV/r Process chemistry and reformulation (  65%) DRV/r Process chemistry dose optimization and reformulation (  60%) Potential cost benefits of optimizing ARVs Adapted from Crawford et al, 2012

27 Point-of-care CD4 is just emerging 3 products available and 1 prequalified Point-of-care testing for VL and EID is imminent Affordability is key Breakthroughs in diagnostic testing and patient monitoring at point-of-care Number of POC technology releases expected (cumulative numbers)

28 Retention rates for ART at 12, 24 and 60 months in selected countries, % 78% 72%

29 Conclusions (1) Global progress on scale-up of ART has been extraordinary. Countries show the way! 15 million can be reached Further scale-up must address disparities and inequities (countries, key populations) With new evidence and new policies, the number of persons eligible for ART will increase Countries face strategic choices and are already taking advantage of new opportunities (early ART, TasP, PrEP)

30 Now is the moment to think and plan beyond the 15 million target This will require forward-looking policies, more effective and innovative approaches, together with further investments ARVs for treatment and prevention are a powerful tool towards ending the HIV epidemic Conclusions (2)

31 Acknowledgements Rachel BaggaleyTony Harries Andrew BallYing-Ru Lo Michel BeusenbergJos Perriens Txema Garcia CallejaYves Souteyrand Wafaa El-SadrJohn Stover Charles FlexnerFrank Tanser Nathan FordBernhard Schwartländer Reuben GranichStefano Vella Ian GrubbMarco Vitoria Tim Hallett Gundo Weiler


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