Global AIDS New Developments in Care

Transcription

1 Global AIDS New Developments in Care Royce C. Lin, MD Assistant Clinical Professor of Medicine scope pledge delivery future Adults and children estimated to be living with HIV, 2005 Western & Eastern Europe Central Europe & Central Asia North America million [ ] [ million] 1.3 million East Asia [ million] Caribbean North Africa & Middle [ million] East South & South-East [ ] [ ] Asia Sub-Saharan Africa 7.6 million Latin America 24.5 million [ million] Oceania 1.6 million [ million] [ million] [ ] Total: 38.6 ( ) million A Global View of HIV Infection 39 million people (33-46 million) living with HIV, 2005 Changes in Life Expectancy : Life expectancy (years) with high HIV prevalence: Zimbabwe South Africa Botswana with low HIV prevalence: Madagascar Senegal Mali UNAIDS, 2006 Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision Deaths at Ages 15-34, With and Without AIDS in South Africa: Deaths (thousands) 2,000 1,600 1, Without AIDS With AIDS UNAIDS, 2006 Source: UN Department of Economic and Social Affairs (2002) World Population Prospects, the 2000 Revision Slide Courtesy of Dr. Mark Dybul 1

2 The Pledge 2000: IAS Durban Conference Break the Silence 2002: WHO Treatment Guidelines in Resource Limited Settings 2002: WHO 3x5 PLAN: Provide antiretroviral therapy for 3million persons by 2005 Slide Courtesy of Dr. Mark Dybul 2005: Universal Access 2005 G8 Summit at Gleneagles, Final Communiqué: working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by % of world population 64% of global HIV/AIDS burden Ugandan example What to use? How? Further afield: more challenges UGANDA AIDS TIMELINE 1 st case AIDS Uganda AIDS Information Centre founded Life in Uganda Museveni to power. Nat l AIDS control program and A.B.C. TASO founded AZT trial started HAART PMTCT trials Free ART! No Access to Therapy TASO: The AIDS Support Organisation ABC: Abstinence, Be faithful, Condoms PMTCT: Prevention of Mother to Child Transmission 2

3 Estimated Total Annual Resources Available for AIDS, PEPFAR ( US$ millions ) World Bank MAP Launch Global Fund Signing of Declaration of Commitment on HIV/AIDS Source: Lancet, 2006; 368: MAP: Multilateral AIDS Programme PEPFAR: President s Emergency Plan for AIDS Relief 5 ART Scale-up in UGANDA Cited as model country Early country response and reduction in prevalence Strong political will Strong international presence Ministry of Health Goals: Provide ART to all needed (~1 million infected, 100, ,000 need ART) Roll-out in phases All regional hospitals by 2003 District hospitals by 2004 Local Health Centers by ,000 by end ,000 by end ,000 by end ,000 by end 2007 Some Challenges in ART Scale-up in Resource-Limited Countries Mulago National Referral Hospital KAMPALA, UGANDA Accumulating toxicities First-line therapy in Africa Weak Infrastructure Constraining healthcare delivery Human Resource Crisis Enough drugs, not enough doctors HIV+TB Overlapping epidemics, treatment challenges 3

4 Case No yo Ugandan woman WHO stage III in 2002 Weight loss (75kg 66kg) Recurrent thrush, vaginal candidiasis Zoster with post-herpetic neuralgia Social: administrative assistant Limited income, can spend up to 40,000 USH on medications ($23 USD) Advised to purchase generic ARV NVP/3TC/D4T (triomune) Case No. 1 Started antiretroviral therapy (generic NVP/3TC/D4T) October months later, no more recurrence of thrush or vaginal candidiasis 8 months later, weight 59kg 65kg 2 yrs later, weight 72 kg Complains I am starting to look like a man Fat loss in thighs, buttocks. Subtle fat loss in face. Otherwise feels well. Case No. 1 Do you think the ARVs are working? A. Yes B. No C. I can t tell without CD4 count D. I can t tell without CD4 and viral load What do you think is causing the problem? A. HIV itself B. Her antiretroviral combination C. Most likely nevirapine (NVP) D. Most likely lamivudine (3TC) E. Most likely stavudine (D4T) What can you recommend? The Global Public Health Approach to HIV Treatment Simple Affordable Tolerable Co-formulated preparations Available and storable Sustainable First Line Antiretroviral Drugs First Line Antiretroviral Drugs Preferential 2 NRTI/NNRTI approach Preferential 2 NRTI/NNRTI approach d4t (or AZT) TDF* or ABC 3TC EFV NVP AZT* or d4t TDF* or ABC 3TC or FTC EFV NVP Triple NRTI alternative approach # NVP/3TC/D4T Lamivudine, abacavir and tenofovir LEAST associated with peripheral neuropathy, Lipoatrophy, pancreatitis, and lactic acidosis among NRTI class. WHO

5 Lusaka, ZAMBIA Suba, KENYA Lusaka, ZAMBIA Kisumu, KENYA Arusha, Tanzania Moshi, Tanzania Suba, KENYA Tororo, UGANDA Medicins Sans Frontiere Chiraduzulu District, Malawi Malawi: Background One of poorest African countries HIV prevalence 19.8% HIV/AIDS leading cause of death Life expectancy 38.5 years MSF Program ART free of charge 2001 Start criteria based on clinical WHO staging Group ART counseling sessions HIV district hospital and 10 rural hospitals Utilized physician/nurse/health care workers Ferradini, Lancet, 2006 Results in MSF ART program Chiraduzulu District, Malawi 2928 on ART by April, 2004 Analysis of 1308 on therapy Median CD4 112 CD4 gain of 165 at 12 months Probability of survival at 12 months was 81% Only 5% stopped ART for intolerance 87% achieved virologic suppression Ferradini, Lancet, 2006 Human Resources Human Resources: NO DOCTORS Inadequate numbers trained Brain drain Impact of HIV on the health care provider community WHO standard: 1 doctor/5,000 people Mozambique: 1 doctor/30,000 people (600 doctors/18 million) Ethiopia: 1 doctor/ 34,000 people Malawi: 1 doctor/ 7,000 PLWHA Africa has 13% of world s population, 64% of the HIV/AIDS disease burden, but only 3% of the health care providers 5

6 HIV/AIDS Impact on healthcare workforce Botswana: 17% of health worker force died between 1999 and 2005 Zambia: 40% of midwives in Lusaka HIV infected South 16% from a sample Africa: from 4 provinces HIV - infected; 20% in ages Training of Trainers TB and HIV : How large is this problem? 1/3 HIV+ co-infected with TB 50-70% TB cases HIV+ Annual risk of TB in TB/HIV co-infected: 10% (10-20% lifetime if not HIV infected) Case fatality rates 20% smear +, 50% smear - Treatment Challenges The Delivery: A Picture is Worth a Thousand Words. Rifampin-based therapy not always available Drug-drug interaction: rifampin and ARVs Efavirenz ok, but teratogenic Disjunction of HIV and TB care Jim Kim and Paul Farmer, NEJM, 2006 Good News : Access June 2006 Geographical region Number of people receiving ARV therapy Estimated need Coverage 5 ARV Therapy: Global Need, June % of the total unmet need Sub-Saharan Africa Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia % 75% 16% 13% (Number of people in millions) Unmet need Receiving ARV therapy North Africa and the Middle East Total % 24% Sub-Saharan Africa Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia UNAIDS, 2006 North Africa and the Middle East 6

7 Patients at a clinic support group in Tanzania Even Mount Kilimanjaro can be climbed. Acknowledgments Disclosure Statements UCSF-PHP Diane Havlir Meg Newman Photography Steve Williams EGPAF, MU, NIH UCSF-ASPIRE Catherine Lyons Guy Vandenberg John Friend Clarissa Ramstead George Beatty Jackie Tulsky Diane Jones Current ACCME guidelines state that participants in CME activities should be made aware of any affiliation or financial interest that may affect the faculty member s contributions. Each faculty member has completed a statement of disclosure, which includes funding sources other than the honorarium received for this program. The faculty have provided the following information on sources of funding that may be perceived as a potential conflict of interest. Royce C. Lin, M.D. has no affiliation or financial interests that may influence the content of this presentation. 7