ART for prevention the task ahead Dr Teguest Guerma WHO/HQS
WHO's role and vision Status of the epidemic Overview Progress and challenges in treatment and prevention scale up ART for prevention Questions to be answered 2
2005 and 2009 G8: 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 2010. 2009 G8 Summit at L'Aquila, Final Communiqué: We have made progress towards universal access in the current global crisis we reaffirm our commitment to address the most vulnerable. 3
Vision WHO vision and directions-hiv Health sector response of Universal access to HIV prevention, treatment care and support 5 strategic directions Enable people to know their HIV status Maximize the health sector s contribution to HIV prevention Accelerate the scale-up of HIV treatment and care Strengthen and expand health systems Invest in strategic information to better inform the HIV response 4
WHO core functions Providing leadership on matters critical to health and engaging in partnerships where joint action is needed; Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; Setting norms and standards, and promoting and monitoring their implementation; Articulating ethical and evidence-based policy options; Providing technical support, catalyzing change, and building sustainable institutional capacity; Monitoring the health situation and assessing health trends. 5
WHO role Consolidate evidence base Stimulate the research agenda Encourage dialogue among relevant global stakeholders 6
WHO/UNAIDS role to promote translation of research to implementation in male circumcision Technical assistance to countries 7
The Epidemic To end 2007 33 million people living with HIV 2.7 million new infections 2 million died for every 12 people who currently have HIV - one new infection occurs annually 8
Associated dramatic increase in TB incidence 9 Chaisson et al 2008
Number of people receiving ART in low- and middle-income countries, by region, 2002 2008 4.5 Millions 4.0 3.5 3.0 2.5 2.0 North Africa and the Middle East Europe and Central Asia East, South and South-East Asia Latin America and the Caribbean Sub-Saharan Africa 1.5 1.0 0.5 0.0 End 2002 End 2003 End 2004 End 2005 End 2006 End 2007 End 2008 10
ART gap in low- and middle-income countries 2002-2007 12000000 10000000 No 8000000 6000000 4000000 Treatment gap 2000000 0 2003 2004 2005 2006 2007 2008 Year Estimations of global need based on CD4 < 200 On ART 11
Trends over time in the median CD4 count at baseline count of 36 715 adults starting ART (2001 and 2006) 12
4,500,000 ART Scale up Progression in Resource Limited Settings (2003 2008) Cumulative Number of Patients Receiving ART Mean Rate of Increase (patients on ART/month) 120,000 4,000,000 100,000 3,500,000 Cumulative Number of Patients on ART 3,000,000 2,500,000 2,000,000 1,500,000 80,000 60,000 40,000 Number of Patients on ART/Month # new starts on ART/month South Africa 60,000 India 6 7000 Thailand 1200 Zambia 1,000,000 20,000 500,000 0 Dec- 03 Jun- 04 Dec- 04 Jun- 05 Dec- 05 Jun- 06 Dec- 06 Jun- 07 Dec- 07 Jun- 08 Dec- 08 0
Antiretroviral therapy coverage and all-cause mortality in South Africa, 2003 2006 14
% pregnant women with HIV and HIV exposed infants who received ARVs for PMTCT (2004 2008) 15
Pressures on costs & resources $ Ongoing transmission Scale up Programme inefficiencies Shift towards costlier first line regimens Increasing use of second line Increased eligibility for ART due to earlier start Lab monitoring Global financial crisis Generic ARV's Low cost monitoring approaches Greater use of co trimoxazole and IPT Shift in attention to other development priorities 16 16
ART financing sources by income level Global Report 2009 latest data reported (39 countries) 100% All other international 75% Dev. Bank Non- Reimbursable Loan Global Fund 50% UN Agencies Multilaterals Bilaterals 25% Public 0% Low Income Low Middle Income Upper Middle Income Total
The funding crunch Resources Available for HIV services Resource needs for country defined UA 30 Resource needs USD billion 20 Available resources $11.3 $13.8 10 $1.4 $1.6 $3.2 $5.0 $6.1 $7.9 $8.8 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Less progress in HIV Prevention Limited number of evidence based interventions Focus on non effective interventions Dichotomy between prevention and treatment Interventions not adapted to epidemic knowledge Limited efficacy of behavioural interventions No global target setting and inadequate MNE Interventions not scaled up at National level. Inadequate support for positive prevention Insufficient political will and funding. 19
Efficacy trials of biomedical prevention tools Intervention Completed Efficacious Male circumcision 3 3 STI treatment 5 1 HSV-2 suppression 2 0 Cervical barriers 1 0 Microbicides 9 0 HIV vaccines 5 1 TOTAL 25 5 Clearly there is a need for new HIV prevention technologies? 20 Adapted from Cohen J, Science 2008
Combination prevention Biomedical Interventions Structural Interventions Community Interventions HIV testing and linkage to care Individual and small group behavioral interventions HIV prevention 21 Adapted from Coates T
Prevention gains of ART Preventing AIDS related death Preventing AIDS morbidity Preventing non AIDS mortality and morbidity Preventing HIV transmission Integration of treatment and prevention 22
Evidence supporting role of ART in preventing HIV transmission Transmission occurs only from persons with HIV HIV Viral load is single greatest risk factor for HIV transmission ART lowers viral load to undetectable plasma levels Use of ART/ARV for PMTCT is proof of concept of reduced transmission Observational cohort data supporting ART for prevention Modelling 23
Conclusions from modeling exercise published by WHO scientists. Universal voluntary HIV testing and immediate ART combined with other prevention interventions: 95% reduction in new HIV cases in 10 years Incidence reduced from 15-20,000 to 1000 per million Prevalence or the number of people living with HIV becomes less than 1% by 2050 Initial resources would be higher but over time, given the reduction in HIV incidence, this approach may provide cost savings Estimated costs are within UNAIDS estimates for Universal Access for a population this size. Theoretical model: It is not WHO policy or strategy 24
ART for prevention/a few questions Are we convinced of the current evidence? What additional research need to be done? Do we have the appropriate technology available? What are the real risks and the potential benefits? How can we expand testing and counselling with respect of human rights? How can we reduce stigma and discrimination among population at high risk of HIV infection and increase access to health services? Is it feasible? Is it affordable? 25
"After climbing a great hill one only finds that there are many more to climb" Nelson Mandela 26
"The time is always right to do what is right" Martin Luther King Jr 27