HIV in the world 2009

Transcription

1 HIV in the world 2009 Joep M.A. Lange Center for Poverty-related Communicable Diseases Academic Medical Center / University of Amsterdam

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9 The failure of HIV prevention Despite positive trends, the number of new infections outpaces the number of people being put on treatment (5 : 2) Concentrated epidemics with high incidence rates in particular populations

10 Why this failure of HIV prevention? Lack of access to prevention tools (education, condoms, clean needles, etc.) In many contexts behavioral change not an easy target Vulnerable position of women & other populations

11 Vulnerable postion of women Leads to great need for female-controlled prevention technologies Female condoms provide alternative to male condom, but ultimately still possibility of male control (apart from cost, etc.)

12 Apart from increasing access to classic HIV prevention tools, what can be done? Circumcision yes Female condom yes Microbicides / diaphragm?/?? STD treatment (GUD, esp. HSV2)??? Vaccines?????????????????????????????? Oral prophylaxis (PREP)?/(yes!) HAART for prevention?/(yes!)

13 A concise history of HIV and its treatment in the developed world 1981: emergence of AIDS epidemic in gay men East and West Coast US 1983/84: discovery of the causative agent: HIV 1987: first active antiretroviral on the market (ZDV) 1996: HAART

14 Why has this been accomplished? The presence of substantial markets in the developed world An unprecedented civil society movement and community engagement

15 Reasons not to introduce HAART in resource-poor settings in 1996 Too expensive Too complex Prevention more important than treatment

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19 What has made the difference for the developing world?

20 Money Establishment of funding mechanisms: World Bank Multicountry AIDS Program (MAP, 2000) Global Fund to fight AIDS, TB and malaria (GFATM, 2002) President s Emergency Plan for AIDS Relief (PEPFAR, 2003/2004)

21 Leadership Community engagement (TASO, etc.) Political leadership Price reduction of antiretrovirals (Accelerating Access Initiative, etc) (2000) Declaration of Commitment of the United Nations General Asssembly Special Session on HIV/AIDS (UNGASS) (2001) WHO Treatment Guidelines + uptake of antiretrovirals in WHO Model List of Essential Medicines (2002) Target setting: WHO s 3by5 initiative

22 However, despite impressive scale-up, Large number still untreated More new infections than people being put on treatment Reliance on cheap fixed dose NNRTI-based combinations for first line therapy Toxicity Durability High early mortality rates (because of late treatment start) Limited availability of second line options Limitid monitoring capacity (no pvl)

23 Major challenges in the antiretroviral scale-up Weak health care infrastructure Low numbers of health care workers Unreliable supply lines Sustainability? Impact of disease-specific programming on fragile health systems?

24 Impact of disease-specific (HIV) programming on fragile health systems? Lack of good data Counters braindrain Has upgraded facilities Has shown that complacency can be overcome

25 The AIDS response did create islands of sufficiency in a swamp of insufficiency (Gorik Ooms, MSF)

26 The way forward We need to move from AIDS-exceptionalism to health-exceptionalism

27 Reality: double burden = double response

28 Priorities HIV treatment resource-poor settings Safer and more robust first line regimens: will not only prevent human suffering, but as well save money in the end these should be studied in African settings; subtypes may matter! Earlier treatment initiation requires massive scale up of (VC)T Cheap and simple CD4 and pvl tests Health systems strengthening (incl. financing)

29 Mortality over four years Cumulative mortality (%) Months after start of ART Sub-Saharan Africa Europe & North America CROI 2007 mortality - 31

30 Median CD4 counts at start of ART Trends over time Europe & North America CD4 cell count at start of ART MSM HET IDU Sub-Saharan Africa Year CROI 2007 CD4 at start 11

31 SAPIT Study (South Africa) 1 Starting Antiretroviral therapy at three Points in Tuberculosis therapy (N = 645) Early integrated treatment: ART as soon as possible after TB treatment (within two months) Later integrated treatment: ART started after the twomonth intensive phase of TB treatment is completed (generally month three or four) Sequential treatment

32 SAPIT Study 2 Safety Monitoring Committee decided to terminate the sequential treatment arm: 55% lower death rate in the two integrated treatment arms Reduction in mortality significant in both patients with CD4+ cell counts < 200/mm 3 and those with counts /mm 3 The two integrated arms will continue until 2010 to determine whether there is any difference between those

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35 Parachute Use to Prevent Death and Major Trauma Related to Gravitational Challenge: Systematic Review of Randomized Controlled Trials Gordon C S Smith, Jill P Pell BMJ VOLUME DECEMBER 2003 Abstract Conclusions: We think that everyone might benefit if the most radical protagonists of evidencebased medicine organized and participated in a double blind, randomised, placebo-controlled, crossover trial of the parachute. Parachutes effectiveness has not been proven with randomised controlled trials.