1. Maximizing the Prevention Benefit of ART in Asia Ying-Ru Lo, MD, DTM&H World Health Organization Regional Office for the Western Pacific, Manila, Philippines Track C WESY02 Treatment as Prevention in Asia International AIDS Society Conference, 3 July 2013 Kuala Lumpur, Malaysia

2. 2 |2 | World Health Organization Western Pacific Region Content Epidemiology and new evidence Programmatic challenges Conclusions

3. 3 |3 | World Health Organization Western Pacific Region Estimated no. of PLHIV by region, 2011 Sub- Saharan Africa East South and South- East Asia Latin America & Caribean Europe and Central Asia Middle East and North Africa Oceania Estimated no. of PLHIV Source: GARP 2012 Asia bears the 2 nd highest burden of HIV (4.9 million of global total of 34 million)

4. 4 |4 | World Health Organization Western Pacific Region ART coverage in selected countries in Asia, 2011 Source: GARP 2012 All ages Country % ART coverage Only 1 country reached > 80% coverage By the end of 2012 number of people receiving ART Globally, 9.6 million (64% of global target) In Asia, 1.3 million

5. 5 |5 | World Health Organization Western Pacific Region Evidence from HPTN 052 HPTN 052 confirms that earlier ART reduces HIV transmission by 96% among discordant couples in stable relationship (Cohen et al, NEJM 2011) Health Affairs 2012

6. 6 |6 | World Health Organization Western Pacific Region China  10-fold increase in ART could decrease the number of HIV- related deaths by 58% and the number of new infections by one-quarter by 2015 (Zhang et al, Sexual Health 2011) Thailand  > 60 % reduction of new HIV cases with increased uptake of HIV testing among key populations and immediate treatment of all HIV-infected people (Peerapatanapokin et al. personal communication) Vietnam  Annual HTC and immediate treatment for key populations, combined with scale-up of methadone maintenance therapy and condom use, will reduce new infections by 81% compared to current interventions (Kato et al, JAIDS 2013) Modelling suggests that HIV testing and ART can avert new HIV infections in Asia

7. 7 |7 | World Health Organization Western Pacific Region A combination of interventions has greater impact than an intervention delivered alone

8. 8 |8 | World Health Organization Western Pacific Region Uptake along the cascade from HIV testing to treatment Communication across the cascade with improved monitoring and evaluation Dealing with acute and early HIV infection Prevention and surveillance of HIV drug resistance Effect of ART at population level depends on ……..

9. 9 |9 | World Health Organization Western Pacific Region Metrics to monitor efficiency of the treatment cascade People with HIV do not know their status Loss of individuals from HIV testing to care and ART Vietnam 2011 % of people living with HIV China 2011 Source: UNAIDS 2012, NCAIDS 2011Source: UNAIDS 2012, VAAC 2011

10. 10 | World Health Organization Western Pacific Region Treatment cascade, Cambodia 2012 Estimated # PLHIV 74,572* (100%) # on ART 48,913 (66%) # in HIV care 6587 (9%) Increasing # of individuals who know their HIV status Invest in monitoring # HIV tested ? ? ? * 2011 Estimates Source: NCHADS 2012

11. 11 | World Health Organization Western Pacific Region Treatment cascade, Thailand, 2008-2011 Source: Adapted from Bhakeecheep (Personal Communication), National Health Security Office Thailand 2012 71% viral load suppression with > 6 months on ART No. of people ? ?

12. 12 | World Health Organization Western Pacific Region Communicating across the treatment cascade To achieve full impact of treatment, communication across services is critical The cascade, although broken down by indicators, must be considered as a whole to estimate population-level impact Requires coordinated programme approach

13. 13 | World Health Organization Western Pacific Region Note on need for unique identifier codes As we move forward to develop and implement a national unique identifier code for use in the HIV testing, care and treatment cascade, we propose a running number plus additional identifying information, such as year, month, and province of birth, to identify persons as they make their way through the treatment cascade in confined clinical settings Frits van Griensven, Cambodia mission, January 2013

14. 14 | World Health Organization Western Pacific Region Individuals with acute HIV infection have 8 to 26-fold higher risk for transmitting HIV vs. those with chronic HIV infection (Pilcher et al, Curr HIV/AIDS Rep 2006, Hollingsworth et al, J Infect Dis 2008, Cohen et al, NEJM 2011) Relative contribution of early phase of HIV infection (3-6 months after infection) has been extensively modelled with differing results varying between 38% during first 4.8 months of HIV acquisition (Powers et al, Lancet 2011) and 2% during first month of HIV acquisition (Williams and Dye in Cohen et al, Plos Medicine 2012) 2012

15. 15 | World Health Organization Western Pacific Region Monitoring adverse events during earlier ART HIV drug (antiretroviral) resistance  impact of longer treatment required for earlier ART on resistance is unknown  monitor early warning indicators Adverse drug reactions Risk behavior compensation (WEPDB0105, Doyle et al; MOLBPE30, Bavinton et al)

16. 16 | World Health Organization Western Pacific Region Low levels of transmitted HIV drug resistance in Asia, 2005-2010 200520062007200820092010 P- value South- East Asia 1.0 (0.6-4.0) 1.3 (0.1 - 3.5) 3.3 (2.8-18.9) 2.9 (0.6-8.2) … 1.0 (0.0-5.8) NS Western Pacific 1.8 (0.2-4.5) 3.3 (1.0-6.6) 1.9 (0.6-3.7) 4.0 (1.6-8.2) 5.6 (3.2-8.7) 0.0 (0.0 -16.1) NS % of HIV drug resistance among ART –naive individuals from the published literature, by year and region (% with at least one drug resistance mutation), 2004–2010 NS: Not statistically significant. Source: WHO HIV Drug Resistance Report 2012.

17. 17 | World Health Organization Western Pacific Region As ART roll out continues, increased rates of HIVDR may occur Routine, standardized, population-based surveillance of HIVDR is imperative and must be in place to detect potential future increase of HIVDR in a timely manner HIV drug resistance surveillance

18. 18 | World Health Organization Western Pacific Region Why ART as prevention implementation research in Asia? Role of ART as prevention in concentrated HIV epidemics in Asia (SW, IDU, MSM) has not been addressed  What needs to be done differently to achieve the level of effectiveness observed in discordant couples in concentrated epidemics?  What is the cost of expanded HIV testing and earlier ART? It is likely that earlier ART can be implemented as the pool of infected people to treat is small compared to generalized epidemics

19. Inter-country workshop on optimizing HIV treatment through the Treatment 2.0 Initiative, Yangon, Sept 13-14, 2012 Planned implementation research (January 2013) ThailandIndonesiaCambodiaVietnamChina PopulationMSM IDU++ All SD couples IDU++ All SD couples MARPs Treat all GoalTo guide future national policy & strategy on earlier ART for MSM and/or FSW To guide future national policy & strategy on earlier ART for SD couples, SWs, MSM and/ or IDU Improve existing policy & strategy Primary objective Feasibility of repeat testing, immediate ART New HTC approaches & uptake Adherence immediate ART Feasibility of identifying partner (network approach), early ART, repeat testing Feasibility improved implementation cascade Programme strengthening ART criteria Irrespective CD4 TDF-based Irrespective CD4 TDF-based Irrespective CD4 or CD4<500 Irrespective CD4 TDF-based (possibly FDC) Irrespective CD4 TDF Enrollment Outreach internet peers NGO and public services for MSM and IDU HTC ART HTC Methadone sites Pre ART HTC ART

20. 20 | World Health Organization Western Pacific Region HIV testing and counselling uptake is low among key populations Substantial number of people diagnosed are not effectively linked to care Attrition is high and adherence suboptimal Monitoring and evaluation systems do not allow communication across the treatment cascade HIV drug resistance surveillance is not sustained Challenges

21. 21 | World Health Organization Western Pacific Region Treatment as (for) Prevention Gathering necessary information to inform programmes and WHO guidelines Serodiscordant couples & programmatic update Implementation & scale-up in countries Impact evaluation Support countries on implementation research WHO/NIH Cambodia, China, Indonesia, Thailand, Vietnam TREAT Asia/WHO Treatment as prevention of HIV workshop WHO China Treatment as Prevention workshop WPRO metrics workshop Support to implementation research in countries Piloting Unique Identifier Codes 2012 20132014 Metrics How to improve efficiency of the HIV testing, care and treatment cascade? 2015 WHO 2013 Guidelines: The use of ARVs for Treating and Preventing HIV

22. 22 | World Health Organization Western Pacific Region Sorakij Bhakeecheep, National Health Security Office (NHSO), Bangkok, Thailand Suwat Chariyalertsak, Research Institute for Health Sciences (RIHES), Chiang Mai University, Chiangmai, Thailand Nittaya Phanuphak, Thai Red Cross AIDS Research Centre, Bangkok, Thailand Duong Duc Bui, Viet Nam Administration of HIV/AIDS Control (VAAC), Ministry of Health, Hanoi, Vietnam Seng Sopheap, National Centre for HIV/AIDS, Dermatology and STD (NCHADS), Ministry of Health, Phnom Penh, Cambodia, Zunyou Wu, Ye Ma, Fujie Jang, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China Masami Fujita, WHO Cambodia, Phnom Penh, Cambodia Masaya Kato, WHO Vietnam Country Office, Hanoi, Vietnam Razia Pendse, WHO Regional Office for South-East Asia, New Delhi, India Dongbao Yu, WHO Regional Office for the Western Pacific Region, Manila, Philippines Acknowledgements