China Free ART's outcomes and Challenges

Transcription

1 China Free ART's outcomes and Challenges Fujie Zhang Clinical and Research Center of Infectious Diseases Beijing Ditan Hospital, Capital Medical University Beijing, China

2 Disclosures I have received honoraria for speaking at educational events or consulting from: AbbVie Gilead Sciences GSK MSD

3 An ambitious treatment target to help end the AIDS epidemic: UNAIDS target % Diagnosed % Treated % Virally suppressed of treated patients will be suppressed Compared with the 4 suppressed rate, a 3-fold increase Models indicates that if all these targets were achieved by, AIDS could be eliminated worldwide by 3 This achievement would create profound healthcare and economic benefits UNAIDS. --: An ambitious treatment target to help end the AIDS epidemic. October 4. Available at: (accessed August 6) UNAIDS: Joint United Nations Programme on HIV/AIDS

4 CHINA Newly detected and reported HIV/AIDS patients in 5 By the end of, 78, (range 6,-4,) adults and children were estimated to be living with HIV 8.6% were female In 5, there were 5,465 cases were newly reported By the end of 5, there are 577,43 people living HIV/AIDS National Health and Family Planning Commission of the People s Republic of China, unpublished data

5 Percentage CHINA Main transmission route of newly diagnosed HIV/AIDS cases Hetero Homo PWID Blood MTCT Unknown National Health and Family Planning Commission of the People s Republic of China. 5 China AIDS response progress report. May 5. Available at: 5.pdf (accessed August 6); National Health and Family Planning Commission of the People s Republic of China, unpublished data Sexual transmission rate 4.5% MSM: men who have sex with men; MTCT: motherto-child transmission; PWID: people who inject drugs

6 ART initiation criteria ART: antiretroviral therapy Zhang F, et al. China Free ART Manual 4, 8, CD4 CD4 35 CD4 5 Any CD4 count

7 Baseline CD4 (per ml) Some patient-related factors associated with late access to ART in China s free ART program Trend for mean P<. 3rd Quantile Median st Quantile Mean Jul Dec 6 Jan Jun 7 Jul Dec 7 Jan Jun 8 Jul Dec 8 Jan Jun Jul Dec Date Jul Dec 6 Jan Jun 7 Jul Dec 6 Jan Jun 7 Jul Dec 6 Jan Jun 7 Jul Dec 6 Mean Median (IQR) 4 (3,87) 3 (34,7) 36 (4,5) 44 8 (4,7) (44,7) 5 4 (47,3) 57 5 (4,4) Wen Y, et al. AIDS Care ;3:6 35

8 Percentage Viral load testing rate remains at over % among HIV-infected population on ART Viral load detection rate ,,3, 8,3 7,3 48,5,3,,6 3, Year National Center for AIDS/STD Control and Prevention, unpublished data

9 Deaths per PY With increasing ART coverage, mortality has declined, regardless of mode of transmission By the end of, FPD, SEX and PWID treatment-eligible patient coverage increased to 8.%, 6.7% and 4.7%, respectively; whereas death rate decreased to 6.7, 7.5 and 5./ PY, respectively 8 Blood/plasma transfusion Sexual Injection drug use Treatment rate (%) Treatment rate (%) Treatment rate (%) Mortality rate (/ PY) Mortality rate (/ PY) Mortality rate (/ PY) PY of HAART (%) Year Zhang F, et al. Lancet Infect Dis ;:56 4 HAART: highly active antiretroviral therapy; PY: person-year

10 Patients (,) Death rate (%) CHINA Treat ALL: treated patients increase rapidly with significantly death rate decrease By the end of November 5, there were 375, on-treatment HIV patients in China. The AIDS death rate decreased 47.7% compared with, which successfully met the government target to decrease death rate by 3% ART patients over the years ART coverage rate and death rate over the years Death ratio(%) Treated ratio ,6 8,6 New treatment patients On-treatment patients,6 4,6 5,6 7, 7,7,5 8,5,5 37, Treated rate (%) Year 3 4 Year Year National Center for AIDS/STD Control and Prevention, unpublished data

11 Life expectancy stratified by virological outcome in adult HIV-infected patients receiving ART in 3 Age group (years) Virological outcome (5% CI) Failure Success Not checked 34. ( ) 57. ( ) 4.5 (3. 5.) ( ) 53.3 ( ). (.77.65) (7.6.4) 48. ( ). (.7.48) (6.5 8.) 45. ( ) 8.8 (8.48.6) ( ) 4.7 (4. 4.4) 7.75 ( ) ( ) 38.6 ( ) 7. ( ) 5.7 (..4) ( ) 6.76 ( ) (8.8.48) 3.8 ( ) 5.67 ( ) (6.5 7.).7 (8.73.6) 5. ( ) National Center for AIDS/STD Control and Prevention, unpublished data

12 Initiate ART treatment as early as possible among all HIV+ patients CD4 >5/μL serodiscordant Total Untreated Eligible for ART Treated Patients, n Patients, n % Patients, n % Total,5 35, , PWID, , Heterosexual transmission 3, , Homosexual transmission 54,4 8, , Blood transfusion Others National Center for AIDS/STD Control and Prevention, unpublished data

13 Cumulative probability of attrition Attrition of HIV-infected patients after start of ART during CD4 (cells/ul) No. at risk Zhu H, et al. PLoS One ;7:e344 Log-rank P-value < Time from start of combination antiretroviral therapy (months) 76 7,465 6,648 7,6 38,6,58, ,

14 Participants (%) Participants (%) Participants Participants (%) (%) % % 8% 7% 6% 5% 4% 3% % % Retention status after and 4 months of combination antiretroviral therapy (cart) % months after cart 8.7%.4% 3.4% Treatment retention treatment non-retentions Treatment non-retention treatment retention National Center for AIDS/STD Control and Prevention, unpublished data % % 8% 7% 6% 5% 4% 3% % % % 4 months after cart.% 3.3% 4.3% Treatment retention treatment non-retentions Treatment non-retention treatment retention

15 Participants (%) Proportion of participants Participants (%) Proportion of participants % % 8% 7% 6% 5% 4% 3% % % % Viral load response after /4 months of combination antiretroviral therapy months after cart 3.% 5.3% 7.5% VL <4 copies/ml VL 4copies/ml VL 4 VL<4copies/ml copies/ml % % 8% 7% 6% 5% 4% 3% % % % 4 months after cart.% 4.8% 6.7% VL <4 copies/ml VL 4copies/mlVL 4 VL<4copies/ml copies/ml National Center for AIDS/STD Control and Prevention, unpublished data VL: viral load

16 Survival rate (%) Comparisons between early ART initiation and standard/late ART initiation with respect to mortality among adult HIV patients who started ART in Baseline CD4+ cell count (cells/μl) 4 months after initiating ART (N=6,75) Number of non-injury deaths Number of people on treatment 44, Unadjusted HR (5% CI), P-value. (.68.),.46.8 (.5.3),. HR adjusted by all factors but not transmission mode (5% CI), P-value.7 (.73.8),.8.86 (.63.),.36 HR adjusted by all factors and transmission mode (5% CI), P-value.7 (.73.8),.8.86 (.63.), CD4 5 CD CD Log-rank P= Time after initiating ART (months) 3 36 From National Center for AIDS/STD Control and Prevention, unpublished data HR: hazard ratio

17 Reported barriers to uptake of and adherence to early ART Individual level Lack of education/understanding Fear of stigma Not wanting to take many pills a day Fear of side effects Feeling well Structural level Lack of (access to) services Lack of availability of ART CATIE. Treatment update, January 4. Available at: /anti-hiv-agents/why-some-people-don-t-want-start-hiv-treatment (accessed August 6); McNairy M, El-Sadr W. Clin Infect Dis 4;58:3 ; Plazy M, et al. HIV Med 5;6:5 3

18 Strategies to overcome barriers to early ART Education Patients Clinicians Guidelines Laws stigma Increase resources Access ART Clinics Testing Social support Integrate care Bolsewicz K, et al. AIDS Care 5;7:4 38

19 Antiretroviral therapy: the future????? Single tablet regimens The integrase era Long-acting injectable? HIV- discovered ZDV/3TC ZDV monotherapy Triple-drug therapy Eron J. CROI 6; Abstract #6 3TC: lamivudine; ZDV: zidovudine

20 Limited treatment options NRTI DUAL BACKBONE TDF/ AZT (generic) + 3TC (generic) 3 rd Agent NNRTIs st line 3 rd Agent PIs nd line EFV (generic) NVP (generic) LPV/r NRTI: nucleoside reverse-transcriptase inhibitor; TDF: enofovir disoproxil fumarate; 3TC: lamivudine; NNRTI: non-nucleoside reverse-transcriptase inhibitor; PI: protease inhibitor; EFV: efavirenz; NVP: nevirapine; LPV/r: lopinavir/ritonavir.

21 MSM: Hard to reach population risk factor of HIV acquisition,in Chinese MSM population : Low eduction level, ethnic minorities,syphilis infection, unprotected anal sex, commercial sex and mulitple partners Self-discrimination, or discrimination and censure from society that makes a group feel shameful, guilty or inferior, is remarkably prevalent among MSM because of traditional Chinese culture, which has had a critical impact on their individual behavior, psychological health status and prevalence of AIDS. Feng Yibing,Bu Kai,Li Meng,Zhang Xiayan,Jin Shanshan,Wang Lu.Meta-analysis of HIV infection incidence and risk factors among men who have sex with men in China,Chin J Epidemiol,5,36(7):75-758

22 PrEP survey online in China Study Aims To investigate the attitudes toward PrEP among Chinese MSM for HIV To identify factors associated with willingness to start PrEP

23 PrEP-China Orangnaziton Beijing Ditan Hosptial USCDC GAP China CDC Blued Base on Blued APP:MSM dating software, registered user reached 7 million January, 7 to February 6, 7, according to the survey of the software registered users to carry out online PrEP usage intention,454 questionnaires were received, the average time of 4.4 minutes. The data were analyzed by descriptive analysis and multivariable logistic regression analysis.

24 Results Characteristics of study population Of 454 MSM involving survey, age range from 8 to 6 years, Age distribution, 8-5 years MSM is 6,% main population 54.57%(57/454) 55,% 5,% 45,% 4,% 35,% 54,6% 3,% 5,%,% 5,%,% 5,%,%,8%,6%,64%,8%,44%,% 8 岁以下 8~5 6~3 3~4 4~5 5~6 6 以上

25 Results 7.68% were ethics minority;7.88% were married; Sexual orientation -6.% considered themselves as homosexuals -.86% as bisexuals -.3% as heterosexuals % were not sure. Year Income Status -38.5% less than RMB -.54% between to 3 RMB -36.7% between 3 to 5, RMB - 5.7% more than 5, RMB

26 广东 山东 北京 河南 江苏 四川 河北 湖南 湖北 浙江 辽宁 陕西 黑龙 广西 安徽 重庆 上海 福建 山西 吉林 江西 云南 甘肃 内蒙 新疆 天津 贵州 海南 宁夏 青海 西藏 澳门 台湾 Results The geographical distribution characteristics of respondents Guangdong, Shandong,Beijing,Henan and Jiangsu province is top five city where MSM current residence. % % 8% 6% 4% % %

27 Results The geographical distribution characteristics of respondents from 35provinces 3 in South China 4 in central China 5 in the Southwest 5 in the north 6 in the Eastern China 5 in the Northwest China Regional Distribution The darker the color, the more representative 3 in the Northeast China

28 Results knowledge on prevention regular screening of HIV, 37.57% -self reported HIV negtive 85.57%,postive 45,% 5.7%,unknown8.64% 4,8 4,% % 37,57% 5 年前 阴性 85,57% 35,% 3,% 在过去 -5 年内 5,% 过去 6 个月 - 年 阳性 5,7%,% 内 5,%,% 过去 6 个月内,% 7,64% 不知道 8,64% 5,%,%,6% 我没有进行过 HIV 检测,%,% 4,% 6,% 8,%,%

29 Results Willingness to Take PrEP Of 454 MSM,77(4.56%)report ed willingness to take PrEP.8% MSM express never use PrEP. 一定会 使用 6% 不太确定绝对 8% 不会使用 % 可能会 使用 4.56% 可能不 会使用 4%

30 Results knowledge of PrEP.44% participants reported that they have know of PrEP, 6.8% never heard about PrEP 64.8% got information from Internet.6% from MSM community,.7% from medical institution,44 % 7,38 % 6,8 % 不知 道没听 过听说 过 5,6%,7 %,6 64,8 % 互联网男同社区组织或社会团体其他同志 / 朋友医疗场所 %

31 Who is a candidate for PrEP? No / inconsistent condom use STI diagnosis Exchange of sex for money, food, shelter, or Drugs Use of illicit drugs or alcohol dependence MSM

32 PrEP starts to gain support in China TDF/FTC is available in China, but only for ART Over 4, ART sites Over 4, ART pats Good adherence, and around 88% pats HIV-RNA<4 copes/ul Lower HIVDR

33 Conclusions The main transmission route is sexual transmission, especially via MSM, in the China As early treatment, treat all, TasP policies are promoted, patients with high CD4 counts and some special populations (PWID) are very challenging for treatment coverage PrEP development in the HIV-negative high-risk population is also very promising China has seen little movement toward adapting PrEP, but something like PrEP is urgently needed in controlling the spread of HIV among MSM in China. Additional formulation of PrEP, more user friendly, more options are needed. PrEP: pre-exposure prophylaxis; TasP: treatment as prevention

34 Milestones of The Free ART Program in China Establishment of the treatment and care division of NCAIDS The first adult free ART treatment pilot was launched in the Shangcai County, Henan Province 3 The four free and one care policy was issued and scaled up throughout the country 5 The first version of National Free ART Manual was published The information system of the national free ART program was initiated The first pilot for pediatric ART treatment was started 7 The pilot of second line treatment was initiated in Henan, Anhui and Hubei Provinces 8 The second revision of the National Free ART Manual was published Free HIV viral load testing became available The th Five Year Action Plan Key Project for pediatric treatment program was launched National Action Plan for the second line treatment was issued Provide drug resistance testing for those who needed The version of information system for the National Free ART Program was initiated The third revision of the National Free ART Manual was published 6 Provide treatment all HIV positives regardless of CD4 count

35 We are grateful to all ART doctors, nurses and laboratory staff in China We are especially grateful to Ma Ye, Zhu Hao, Cheng Wei, Wu Yasong, Zhang Rao and Dou Zhihui 35