1. Fabio Mesquita, MD, PhD Director of the Brazilian Ministry of Health’s HIV/AIDS and Viral Hepatitis Department www.aids.gov.br July 23th, 2014 TasP – Leadership perspective The Brazilian Ongoing Experience

2. HIV Prevalence Rate

3. Aids Detection Rate SOURCE: The Brazilian Ministry of Health’s HIV/AIDS and Viral Hepatitis Department (MS/SVS/Departamento de DST, Aids e Hepatites Virais) (1) Cases notified in SINAN and registered in SISCEL/SICLOM by June 30 2012 and declared in the 2000 – 2011 SIM Preliminary data Detection Rate Year Brazil North Northeast Southeast South Midwest

4. HIV/Aids in Brazil  Deaths due to AIDS, annual average: 12,000 15,000, considering 30% due to underreporting and misreporting

6. What have we learned? We were relatively successful in controlling the epidemic, but were finding it hard to move on Need to strengthen and redirect the national response How? Evidence Based Decision Innovation Creativity

7. Classic Prevention Condoms Harm Reduction

8. Enabling Environment

9. Treatment as Prevention “The results have galvanized efforts to eliminate the global AIDS epidemic” Dr. Bruce Alberts, editor of Science magazine

10. New Testing Algorithms NEW GOVERNMENT DIRECTIVE (DECEMBER 2013) It introduces five new algorithms aimed at increasing access to testing and diagnosis  Algorithm 1: screening + confirmation -> RT finger prick  Algorithm 2: screening RT finger prick + confirmation Oral Fluid  Algorithm 3: screening 3rd generation immunoassays + confirmation VIRAL LOAD quantification  Algorithm 4: 4th generation immunoassays as screening + confirmation VIRAL LOAD quantification  Algorithm 5: combines 3rd generation immunoassay screening followed by Western Blot/Imunoblot confirmatory test

11. FOCUS on Key Population Focus on Key Populations  60 financed projects  Use of screening with oral fluid RT technology  4 populations: Trans Gay and other MSM PUD SW  4567 people tested by July 11

12. New Treatment Protocol The new Clinical Protocol and Therapeutic Guidelines (CPTG) for Treatment of the HIV Infection in Adults was discussed with an Advisory Board of experts, submitted to public consultation for 30 days, and published by Government Directive no. 27, on November 29, 2013. CPTG is available at: -www.aids.gov.br/pcdt (pdf and html) -Apple stores and Google Play (App)

13. New Treatment Protocol One of the highlights amongst the CPTG’s main new items is a recommendation to initiate antiretroviral therapy for all HIV positive people, regardless of CD4, based on the possible impact on morbidity and mortality, but also on the reduction of HIV transmission. A Public Health Approach. Brazil was the first developing country and the third country in the world to use treatment as prevention for all people with HIV and in its national recommendations.

14. Use of fixed recommended dose for first-line preferred regimen: TDF + 3TC + EFV

15. Expansion of HIV Management to Primary Care At the beginning of the AIDS epidemic: -High morbimortality – “AIDS- deaths” -Few drugs available -Many pills a day -Many side effects -Low treatment success -HIV as acute disease Specialized services Specialists Presently: -Decrease in mortality, increased survival -Many treatment options -Few pills a day -Few side effects -High treatment success -HIV as chronic disease New care model Participation of Primary Care and Specialist Services in caring for PLWHA

16. Our goal for 2014: at least 100 thousand more people in treatment New PLWHA on ART in the first semester of each year. Brazil, 2012-14 2014: a 30% increase, approximately, when compared to the same period in 2013

17. In 2014, the CD4 counts of 40% of the patients who began treatment was greater than 500 Distribution of individuals who began ART according to CD4 counts carried out 6 months earlier at most, by year of beginning in Brazil, 2009-2014* (*) Up to June 2014.

18. TasP is integrated with other strategies for a new treatment policy in Brazil TREATMENT 2.0 Adapt delivery systems Mobilize communities POC and other simplified monitoring Optimize drug regimens Reduce costs Combined fixed doses VIVA MELHOR SABENDO New diagnosis algorithms New treatment protocol – lines of treatment HIV Management in Primary Care

19. 90 / 90 / 90: a Latin America Goal

20. 90%

21. 90 / 90 / 90: a Latin America Goal Jun/14 90%