HIV behandeling, een internationaal perspectief LUT LYNEN DEPARTEMENT KLINISCHE WETENSCHAPPEN ITG

Transcription

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2 HIV behandeling, een internationaal perspectief LUT LYNEN DEPARTEMENT KLINISCHE WETENSCHAPPEN ITG

3 1981: The beginning of AIDS

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6 The different faces of AIDS in the early days

7 HIV prevalence world map

8 WAAROM?

9 HIV STRUCTUUR HIV is a Retrovirus

10 HIV uses CD4 to attach to T cells CD4 molecule is expressed at the cell surface of a subset of T cells (T-helper cells) but also on monocytes, macrophages, dendritic cells

11 CD4 lymphocyte: key organiser of the immunological defence B-Lymphocytes (antibodies) Bacterial infections CD4+ MACROPHAGE TB PARASITES CD8+ VIRUS

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13 By January 2014, FDA had approved 28 different drugs weak and toxic strong and toxic strong and safe Elvitegravir The Dawn of HAART: Combination ART becomes available. Hit Hard, Hit Early Era Dolutegravir

14 29.4% 8.8%

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18 Bridging the gap

19 «AIDS exceptionalism»

20 July 2000: XIII International aids conference, first in Africa

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23 US$ million Less than US$ 1 million 59 Total available resources for AIDS Signing of Declaration of Commitment on HIV/AIDS,UNGASS UNAIDS 292 World Bank MAP launch Gates Foundation 1623 PEPFAR Global Fund 8.9 billion 8.3 billion 13 billion 10 billion : 113 billion USD invested in AIDS response in SSA [i] data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006); [ii] data: Mann.&. Tarantola,

24 Price reduction through generic competition 2015: 85% of ARV come from India 3TC-D4T-NVP

25 Pilot treatment programs from 2002 on

26 ART scale up in the Developing Access and implementation has been greatly influenced by WHO guidelines World

27 When to start? WHO stage 4 or CD4 < 200 URGENT!

28 Target 2015: 15 M 10X10 3X5

29 New knowledge leads to periodic updating of guidelines Industrialized settings The Dawn of HAART: Combination ART becomes available. Hit Hard, Hit Early Era WHO guidelines Treat those with greatest need (Treat at CD4 < 200) "The 3 by 5 Initiative

30 When is Antiretroviral Therapy Started? Review of data from from 42 countries, 176 sites, n=33,008 Since 2000, CD4 at initiation in developed countries stable at about 175 cells/µl, increasing in Sub-Saharan Africa from cells/µl. Egger M, 14 th CROI, Los Angeles 2007, #62.

31 Problem of late start IRIS

32 High Rate of Mortality 15% of HIV-infected cohort Bassett et al. AIDS 2010

33 New knowledge leads to periodic updating of guidelines Industrialized settings The Dawn of HAART: Combination ART becomes available. Hit Hard, Hit Early Era 2006 WHO guidelines Treat if CD4 < 200, but consider if < WHO guidelines Treat those with greatest need (Treat at CD4 < 200) "The 3 by 5 Initiative"

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35 Very effective treatment = Lazarus syndrome

36 HAART effect on life expectancy is enormous in high burden countries

37 VOILÀ CE QU'UN MALADE DU SIDA Complex DOIT AVALER combinations CHAQUE SEMAINE, SANS GUERIR POUR AUTANT FDC 1/day

38 New knowledge leads to periodic updating of guidelines Industrialized settings The Dawn of HAART: Combination ART becomes available. Hit Hard, Hit Early Era 2010 WHO guidelines Treat at CD4 < WHO guidelines Treat if CD4 < 200, but consider if < 350 Commitment to UA WHO guidelines Treat those with greatest need (Treat at CD4 < 200) "The 3 by 5 Initiative"

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40 New knowledge leads to periodic updating of guidelines 2013 WHO guidelines Treat at CD4 <500 Treatment as Prevention (TASP) Industrialized settings The Dawn of HAART: Combination ART becomes available. Hit Hard, Hit Early Era 2010 WHO guidelines Equity key principle Treat at CD4 < WHO guidelines Treat if CD4 < 200, but consider if < 350 Commitment to UA WHO guidelines Treat those with greatest need (Treat at CD4 < 200) "The 3 by 5 Initiative"

41 2015

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43 One of the greatest successes in history of medicine

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45 2003 CD4 <200

46 2016 Treat all

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48 2016: New goal to eliminate HIV as a public health problem by 2030 Source: UNAIDS/WHO estimates. The red shading shows future targets.

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50 New targets: Cascade: % 80% 60% Target 1: 90% of HIV+ people diagnosed 90% 36.9 million 33.2 Target 2: 90% of diagnosed people on ART 81% Target 3: 90% of people on ART with HIV RNA suppression 73% million 29.5 million 26.9 million 40% 20% 0% HIV Positive People Diagnosed On ART Viral Suppression

51 THANK YOU