Immediate Offer of HIV Treatment: How To Deliver on the Second 90 (including Supply Chain Management and Drug Stockouts)

Transcription

1 Immediate Offer of HIV Treatment: How To Deliver on the Second 90 (including Supply Chain Management and Drug Stockouts) Roselyne TOBY,MD, ID specialist Infectious Disease Unit/Yaounde Central Hospital ANRS Site Cameroon DLMEP-MoH

2 Outline Background and introductory remarks Second 90 challenges Some solutions 2

3 By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy 3

4 4

5 Why Early ART initiation? TEMPRANO 2056 patients, Ivory Coast 44% lower risk of death or severe HIV-related illness in CD group START 4685 patients, 215 sites, 35 countries Risk of death was 57% lower among those treated early EARLY ART Impact on morbidity, mortality as major outcomes (severe HIV morbidity, HIV disease progression) HIV transmission without significant increase in SAEs. viral suppression rates exceeding 95% (START)and 5

6 WHO ARV Guidelines Evolution : 2002 to 2015 Topic When to start 1 st Line ART 8 options - AZT preferred 2 nd Line ART 3 rd Line ART Viral Load Testing CD4 200 CD4 200 CD Consider CD4 350 for TB Boosted and non-boosted PIs 4 options - AZT preferred Boosted PIs -IDV/r LPV/r, SQV/r 8 options - AZT or TDF preferred - d4t dose reduction Boosted PI - ATV/r, DRV/r, FPV/r LPV/r, SQV/r CD Regardless CD4 for TB and HBV 6 options & FDCs - AZT or TDF preferred - d4t phase out Boosted PI - Heat stable FDC: ATV/r, LPV/r CD Regardless CD4 for TB, HBV PW and SDC - CD4 350 as priority 1 preferred option & FDCs - TDF and EFV preferred across all pops Boosted PIs - Heat stable FDC: ATV/r, LPV/r Towards treatment initiation at any CD4 cell count Continue with FDC approach and phased introduction of new options (DTG, EFV 400 ) Add more heat stable PI options (DRV/r) and new strategies (NRTI sparing regimens) None None None DRV/r, RAL, ETV DRV/r, RAL, ETV Encourage HIV DR to guide No No (Desirable) Earlier initiation Simpler treatment Less toxic, more robust regimens Yes (Tertiary centers) Yes (Phase in approach) Better and simpler monitoring Yes (preferred for monitoring, use of PoC, DBS) Support for scale up of VL using all technologies 6 Courtesy of Eholie S. WHO, 2015

7 Clin Infect Dis. (2011) 52 (6):

8 Recommandations OMS

9 Second 90 challenges 9

10 ART coverage and GAPS (!) UNAIDS, Report on the global AIDS epidemic,

11 Challenges: Health care services Maintaining quality care + ART adherence Retention in care Continuous drug supplies Lifelong, high-quality HIV treatment will require well-functioning, accessible, and affordable health care services. 11

12 Challenges: Health care services Retention rates for ART at 12, 24 and 60 months for selected countries Retention in HIV Program Meeting Report, Geneva,

13 Challenges: Health care services Centralization of HIV treatment services in many settings reduces the success of treatment program Tanser F et al. Science,

14 Challenges: Lack of human ressources Health personnel/ Inhabitants Africa World Doctors Nurses Pharmacist/auxiliaries Dentists Source: World Health Statistics

15 Challenges: societal aspects Stigma and discrimination (eg: in one HIV-infected children lost to follow-up in Malawi) Punitive laws criminalizing HIV exposure transmission or non-disclosure Punitive laws targeting key populations 15

16 Challenges : patients treatment acceptance 2562 HIV-infected, 743 eligible for ART (CD4 <200 cells/µl, 2009 SA guidelines) 148 refused to initiate ART Katz IT, AIDS

17 Challenges : Money, money, money Need in increase of: In-country contributions Global funding :Global Fund and PEPFAR Source : UNAIDS, Report on the global AIDS epidemic,

18 Persistent dependency on international Dependency of countries national HIV response on international sources financing Source : UNAIDS, Report on the global AIDS epidemic,

19 Some solutions 19

20 Tailored delivery strategies Flexible evening and weekend clinic hours for adult men, workplace programs Partnerships with the private sector and service systems Tailored approaches critical for key populations: people living in remote areas, migrants, prisoners... Decentralization Task shifting+++ 20

21 Tailored delivery strategies Family-centred service delivery model marked increase in paediatric HIV treatment uptake (Uganda) 21

22 Simple, standardized and well tolerated regimen 22

23 Community based interventions: MSF experiences Adherence clubs (over 231 clubs and approximately 6000 patients) Community points of distribution of ART drugs (DRC) Community groups of antiretroviral therapy (Mozambique) Spacing appointments and Fast Track renewal antiretroviral treatment (Malawi) Use of trained non professional to allow community adherence+++ Source: Administration communautaire de la the rapie antire trovirale, MSF-ONUSIDA,

24 No drug stocks-out!!! Ceilings for ART drugs for facilities* Simplified drug procurement chain at national level Multiple donors for ordering and procurement* Countries Advocacy to mobilize funds * Anthony D Harries and al: Bull World Health Organ Feb; 85(2): Erick J schouten and al: J Int AIDS Soc. 2011; 14(Suppl 1): S4. Published online 2011 Jul 6 24

25 Thank you! 25