who guideines overview background for gsg briefing 19 july g hirnscha
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HIVTRANSCRIPT
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2013 WHO Consolidated ARV Guidelines
Summary of Major Recommendations and Estimated Impact
GSG Briefing July 19, 2013
Gottfried Hirnschall, Director HIV Department, WHO
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ART Scale up : Progress Towards Global Targets
WHO Global ART report, 2013
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Number of pregnant women living with HIV needing and receiving ARVs for PMTCT, 2005-2011
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
2005 2006 2007 2008 2009 2010 2011
14%
56%
1,570,000 1,470,000
HIV+ pregnant women receiving ARVs for PMTCT HIV+ pregnant women needing ARVs for PMTCT
(WHO, Global Report 2013)
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Number of children acquiring HIV infecSon in low- and middle-income countries, 1996-2012
No ARV prophylaxis for PMTCT
Current ARV prophylaxis coverage for PMTCT
800,000 pediatric infecSons averted
~290,000 new pediatric infecSons 2012
(WHO, Global Report 2013)
2015
2015 goal: 40,000 new pediatric infecSons
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30th June 2013
01 | Results: The gap between adult and child ART coverage in 20 high burden
countries is widening
Source: Global AIDS Response Progress ReporGng (WHO/UNICEF/UNAIDS) and 2013 UNAIDS esGmates.
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Clinical
Guidance for Programme Managers
HOW TO DO IT? Service delivery DiagnosScs Drug supply
HOW TO DECIDE? PrioriSzaSon Equity and ethics Monitoring & EvaluaSon
WHAT TO DO? When to start or switch Which regimen to use How to monitor Co-infecSons & co-morbidiSes
Operational
WHO 2013 Consolidated ARV Guidelines
Simplification and consolidation across:
- Continuum of HIV care
- Ages and populations
- Clinical, operational and programmatic guidance
- Existing and new recommendations
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Treatment 2.0
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Clinically relevant oEarlier iniSaSon of ART (CD4 500) oImmediate ART for children < 5 years oART iniSaSon for all pregnant and breas`eeding women (OpSon B/B+) and lifelong ART (OpSon B+) oHarmonizaSon of ART across populaSons (e.g., adults and pregnant women) and age groups oSimplied, fewer, and less toxic 1st-line regimens (TDF/XTC/EFV)
Key New RecommendaSons in 2013 WHO Guidelines
OperaSonally relevant o Use of Fixed Dose CombinaSons as a
preferred approach o Improved paSent monitoring to
support bejer adherence and detect earlier treatment failure (increased use of VL)
o Recommend task shiming, decentralizaSon, and integraSon
o Community based tesSng to complement broader HTC
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Summary of Changes in RecommendaSons When to Start in Adults
TARGET POPULATION (ARV-NAIVE) 2010 ART GUIDELINES 2013 ART GUIDELINES
STRENGTH OF RECOMMENDATION
& QUALITY OF EVIDENCE
HIV+ ASYMPTOMATIC CD4 350 cells/mm3
CD4 500 cells/mm3 (CD4 350 cells/mm3 as a priority)
Strong, moderate-quality evidence
HIV+ SYMPTOMATIC
WHO clinical stage 3 or 4 regardless of CD4 cell count No change
Strong, moderate-quality evidence
PREGNANT AND BREASTFEEDING WOMEN WITH HIV
CD4 350 cells/mm3 or WHO clinical stage 3 or 4
Regardless of CD4 cell count or WHO clinical stage
Strong, moderate-quality evidence
HIV/TB CO-INFECTION
Presence of acGve TB disease, regardless of CD4 cell count
No change Strong, low-quality evidence
HIV/HBV CO-INFECTION
Evidence of chronic acGve HBV disease, regardless of CD4 cell count
Evidence of severe chronic HBV liver disease, regardless of CD4 cell count
Strong, low-quality evidence
HIV+ PARTNERS IN SD COUPLE
No recommendaGon established
Regardless of CD4 cell count or WHO clinical stage
Strong, high-quality evidence
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RecommendaSons: CD4 Independent CondiSons
INITIATE ART REGARDLESS OF CD4 COUNT OR CLINICAL STAGE
RECOMMENDATION
ADULTS WITH HIV
and acGve TB disease Strong, low-quality evidence
and HBV co-infecGon with severe liver disease
Strong, low-quality evidence
who are pregnant or breas^eeding Strong, moderate-quality of evidence
in a HIV serodiscordant partnership
Strong, high-quality evidence
CHILDREN < 5 YEARS OLD WITH HIV
Infants diagnosed in the rst year of life
Strong, moderate-quality of evidence
Children infected with HIV between one and below ve years of age
CondiKonal, very-low-quality evidence
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RaSonale: Shim from OpSon A to B+ or B
Major issue now is not when to start or what to start but whether to stop
BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY & PUBLIC HEALTH
Ensures all ART eligible women iniGate treatment
ReducGon in number of steps along PMTCT cascade
Prevents MTCT in future pregnancies Same regimen for all adults (including pregnant women)
PotenGal health benets of early ART for non-eligible women
SimplicaGon of services for all adults
Reduces potenGal risks from treatment interrupGon
SimplicaGon of messaging
Improves adherence with once daily, single pill regimen
Protects against transmission in discordant couples
Reduces sexual transmission of HIV Cost eecGve
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30th June 2013
CD4
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EsSmated impact on incidence and deaths of implemenSng the new recommendaSons
WHO Global ART report, 2013
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EsSmated cost of implemenSng the new recommendaSons
WHO Global ART report, 2013
10% increase of the 22-24 billion USD annually for full HIV response
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30th June 2013
Child adult coverage gap is widening, other key populaSons lag behind
Switching from 2010 to 2013 guidelines will enhance impact on lives & epidemic
15 by 15 is within reach
Global Update on HIV Treatment 2013: Key Findings and Messages
9.7 million on ART, 1.6 more than in 2011
630 000 children on ART, only 64 000 more than in 2011
Eligibility increase from 17 to 26 m Mortality/ incidence decline by 1/3
HIV treatment scale-up is paying o ARVs saved 4.2 million lives and
prevented 800 000 child infecSons
Many countries do well, but some need intensied support
In high burden countries, ART coverage varies from 30% to 90%
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Next Steps Global level
Launch of guidelines at IAS KL (30 June 2013) Full guidelines Short summaries in 6 UN languages + Portuguese
Regional level Regional disseminaGon workshops
All regions planned for the next 3-6 months UN and implemenGng partners support
Country level Country adaptaGon
Policy and naGonal guidelines updates ImplementaGon roll out
7/26/13 16
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30th June 2013
Find the New 2013 WHO Consolidated ARV Guidelines on www.who.int/hiv