the 2013 consolidated who guidelines on arv use: implementing to achieve maximum impact
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The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact
Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO
Getting to Zero mortality
1. Taking stock: How close is Asia to zero HIV-related deaths?
2. Identifying current bottlenecks and response gaps
3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment
4. Looking ahead: current and future opportunities
Getting to Zero mortality
1. Taking stock: How close is Asia to zero HIV-related deaths?
2. Identifying current bottlenecks and response gaps
3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment
4. Looking ahead: current and future opportunities
Getting to Zero mortalityGetting to Zero mortality
Eastern Mediterranean
Europe South-East Asia and the West-
ern Pacific
Africa The Americas All low- and middle-income
countries
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%2009 2010 2011 2012
51%64%
Proportion of eligible adults living with HIV receiving ART, by region, 2009–2012
Adult ART coverage in Asia is below the global average for low- and middle-income countries
Source: UNAIDS/WHO Coverage: number of adults receiving ART in 2012 / number of adults eligible for ART in 2012 according to 2010 guidelines.
Indonesia
Bangladesh
Nepal
Sri La
nka
Malaysia
Maldives
Myanmar
IndiaASIA
Viet Nam
Philippines
Thailan
d
Papua New
Guinea
Cambodia
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Asia:51%
ART coverage in selected Asian countries, 2012
Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines
Great variability in access to ART in Asia
Source: UNAIDS/WHO
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0
500 000
1 000 000
1 500 000
2 000 000
2 500 000
GlobalAsia
In Asia: - 650,000 lives saved 2005-2012Yet: - 260,000 died in 2012 alone
30%
20%
Peak: 2005
HIV-related deaths have decreased in Asia, but less than globally (in LMICs)
Source: UNAIDS/WHO
1. Taking stock: How close is Asia to zero-AIDS related deaths?
2. Identifying current bottlenecks and response gaps
3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment
4. Looking ahead: vision and opportunities for the future
Getting to Zero mortality
Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam
Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010
In Asia, 1 in 3 patients started ART at CD4<100* in 2010
Still too many people start ART late
Est. number of PLHIV
No. PLHIV diagnosed &
Reported
PLHIV in care (pre-
ART+ART)
PLHIV on ART No. receiving VL
VL suppressed 0
100 000
200 000
300 000
400 000
500 000
600 000
700 000
800 000
900 000100%
50% 42%
22% 16% 13%
Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013
Cascade of HIV diagnosis to viral suppression, China, 2012
Too many people are not aware of their HIV status
Cam
bodi
a(2
007/
2011
)
Chin
a (2
012)
Indi
a (2
012)
Mon
golia
(2
012)
Mya
nmar
(200
8/20
09)
Nepa
l(2
009/
2011
)
Phili
ppin
es
(201
1)
Thai
land
(2
012)
Viet
Nam
(2
012)
Med
ian
0
10
20
30
40
50
60
70
80People who inject drugsMen who have sex with menFemale sex workers
Key populations: too many unaware of their HIV status
Percentage of key populations who received an HIV test in the last 12 months and know their results
%
52%41%
33%
Source: WHO, 2013
Est. number of PLHIV
PLHIV diagnosed and reported
PLHIV in care (pre-ART+ART)
PLHIV currently receiving ART
No. receiving VL VL suppressed 0
50 000
100 000
150 000
200 000
250 000
300 000 100%
78%
32% 28%
n.a n.a
Too many people are lost to care after diagnosis
Cascade of HIV diagnosis to care, Vietnam, 2012
Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013
12 months 24 months 60 months 0
10
20
30
40
50
60
70
80
90
100
84%80%
69%MalaysiaCambodiaChinaPapua New GuineaIndonesiaWeighted av-erage
Still too many people are lost from ART: Retention at 12, 24 and 60 months
Still too many people are lost from ART: Retention at 12, 24 and 60 months
%
Source: WHO/UNAIDS
010203040
50607080
90100
27
16 19 18 20 1712
36
22 2415
61
31
18
1
51
2215
919
52
17 17
50
36
0
2230
% TDF % d4T
• 44 different first-line regimens• 119 different second-line regimens
• 30% of patients still on d4T• Only 18% of patients on TDF
Source: WHO ARV Use Survey, 2013
Are the optimal regimens being used?
Proportion of d4T and TDF among adult patients on 1st line ART by end of 2012
%
Still too many people who:- do not know their HIV status- start ART late - take sub-optimal regimens- are lost to follow-up- do not have access to comprehensive
package of care services
Important challenges in Asia
Key populations require tailored approaches and service models
1. Taking stock: How close is Asia to zero-AIDS related deaths?
2. Identifying current bottlenecks and response gaps
3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – earlier, better, and simpler treatment
4. Looking ahead: current and future opportunities
Getting to Zero mortality
• Threshold moved to < 500 CD4 (adolescents, adults, MSM, TG, SW, PWID)
• Priority for reaching all HIV+ symptomatic persons and those with CD4 < 350
• CD4-independent situations for ART initiation:– HIV/TB coinfection and HBV advanced liver disease– HIV serodiscordant couples – Pregnancy: “options B/B+”– Children less than 5 years of age
Earlier treatment initiation
Simpler and better treatment: one regimen for all
• Harmonize regimens : Adults, Pregnant Women (1st trimester), Children >10 years, TB and Hepatitis B
• Simplicity: effective, well tolerated, once-daily FDC facilitates adherence
• Streamlines drug procurement and supply chain management• Affordability: cost declined significantly since 2010
Preferred 1st line regimen: TDF + 3TC (or FTC) + EFV
Viral load is recommended as the preferred monitoring approach to diagnose and confirm ARV treatment failure
If viral load is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure
Improved monitoring of ART Response
Key objective: earlier identification of treatment failure
Expanded HIV testing and counselling
Provider-Initiated Testing and Counselling (PITC)
Community-based testing (June 2013)
HIV Self testing (HIVST) • FDA (USA) approval of OraQuick for HIVST (July 2012)• Evolving approach, particularly relevant for key populations • Legal, ethical, and public health implications
Countries are already moving: CD4 threshold for ART initiation
* As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions
2
13
1
200
350
500
88 200/350
500
Number of countries surveyed: 16
National policies as of August 2013 Likely changes
Countries are already moving: PMTCT – move to option B or B+
* As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions
2
9
5 Option A
Option B
Option B+
610 Option B
Option B+
Number of countries surveyed: 16
National policies as of August 2013 Likely changes
20112012
20132014
20152016
20172018
20192020
20212022
20232024
2025 0
500 000
1 000 000
1 500 000
2 000 000
2010 guidelines 2013 guidelines
Major reduction in mortality expected
Estimated annual HIV-related deaths
-39%
Source: Special analysis conducted by Futures Institute, 2013
1. Taking stock: How close is Asia to zero-AIDS related deaths?
2. Identifying current bottlenecks and response gaps
3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment
4. Looking ahead: current and future opportunities
Getting to Zero mortality
The path towards “Zero deaths”
Scale up Innovate Research and develop
Testing and ART to all people
living with HIV
Drugs
DiagnosticsFocus on key populations
Linkages and retention
Comprehensive care models
Service delivery models
Cure
Preventive vaccine
The path towards “Zero deaths”
Testing and ART to all people
living with HIV
Drugs
DiagnosticsFocus on key populations
Linkages and retention
Comprehensive care models
Scale up Innovate
Service delivery models
Cure
Preventive vaccine
Research and develop
Scale up Innovate Research and develop
The path towards “Zero deaths”
Testing and ART to all people
living with HIV
Drugs
DiagnosticsFocus on key populations
Linkages and retention
Comprehensive care models
Service delivery models
Cure
Preventive vaccine
Potential strategies to cure HIV
Source: IAS
Conclusions: the way forward
1. Implement new ARV Guidelines: earlier, better, simpler ART
2. Focus on key populations: community-based models for testing; comprehensive care
3.Enhance service quality and integration for broader and sustained impact.
4.Lead Innovation and Increase Investments
Rachel Baggaley, Andrew Ball, Jhoney Barcarolo,Michel Beusenberg, Meg Doherty, Nathan Ford, Vincent Habiyambere, Ying-Ru Lo, Amaya Maw-Naing, Razia Pendse, Jos Perriens, Nathan Shaffer, Marco Vitoria, Gundo Weiler
Acknowledgements
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