90-90-90 A smart and doable investment
As of December 2013 Adults and children living with HIV Adults and children newly infected Adult & child deaths due to AIDS 35.0 million [33.2 million 37.2 million] 2.1 million [1.9 million 2.4 million] 1.5 million [1.4 million 1.7 million]
The other side of the story New infections Deaths due to AIDS 38% decrease 35% decrease ]
Rapid Treatment Scale up Prevents death Prevents new HIV infection Saves money
HIV treatment can normalize survival Expected impact of HIV treatment in survival of a 20 years old person living with HIV in a high income setting (different periods)
Dramatic impact of HIV response on life expectancy years 70 60 50 40 1960 1970 1980 1990 2000 2010 Source: World Bank life expectancy data Slide courtesy D Birx, PEPFAR
PARTNER study: No transmission when viral load undetectable 1110 serodiscordant couples Two-year interim analysis shows no cases where someone with a viral load under 200 copies/ml transmitted HIV
Incidence rate ratio A clear correlation between HIV treatment and incidence 1.1% (0.8%-1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage. 1.0 0.8 p=0.325 p=0.003 p=0.0001 p=0.013 0.6 0.4 0.2 0 ART & HIV incidence: Hlabisa, South Africa 0% 30% 60% ART coverage Source: Tanser et al. Science 2013;339:966-971
Expanding access to ART is a smart investment: Case of South Africa Source: Expanding ART for Treatment and Prevention of HIV in South Africa: Estimated Cost and Cost-Effectiveness 2011-2050. PLoS ONE 7(2):e30216
Treatment continues to expand 15 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20142015 2015
Treatment continues to expand 15 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2012 2013 2014 2015 2015
UNAIDS PCB calls for new targets Targets drive progress New scientific evidence Post 2015 Accountability A winnable challenge
The choices Status quo Continue the current pace WHO 2013 guidelines Rapid scale-up to universal access
The treatment target
The new treatment paradigm 90% 81% 73% Single target Cascade target Death Death and transmission Number Equity Incremental funding Frontload Investments
Global ART coverage 37% Adults and children Source: UNAIDS 2014
Antiretroviral coverage varies by region 51% 21% 42% Western and Central Europe and North America 11% Eastern Europe Central Asia 33% Caribbean Middle East and North Africa Asia and Pacific 45% 37% Latin America Sub-Saharan Africa Source: UNAIDS estimates 2014
90% of HIV+ people tested is possible
HIV+ population tested at least once 100 90 80 70 60 50 40 30 20 10 Women Men 0 Burkina Faso 2010 Burundi 2010 Cameroon 2011 Zimbabwe 2010-11 Ethiopia 2011 Uganda 2011 Malawi 2010 Rwanda 2010 Source: Demographic and Health Surveys
90% of eligible people on treatment is possible
high coverage in several countries 72% Brazil 71% Botswana Brazil UNGASS Country Progress Report (2012) UNAIDS Situation Room
Record number of people who tested positive for HIV went on to access ARV HIV, Sub-Saharan Africa 90% Source: UNAIDS 2014
90% virally suppressed is possible
Site A Site B Site C Site D Site E Site F Site G Site H Site I Site J Site K Site L Site M Site N Site O Site P Site Q Site R Site S Site T Total Proportion (95% CI) of patients with undetectable VL in a nationally representative sample of HIV-infected adults on ART in Rwanda 100.00% 80.00% 83% 60.00% 40.00% 20.00% Source: Basinga P et al. (2013) PLoS
Preparedness is key
Challenges ahead: 1- Societal Lack of knowledge of HIV status Punitive policies and laws Stigma and discrimination
Source: UNAIDS / National Commitments and Policy Instrument (NCPI)
Challenges ahead: 2- delivery systems Relative likelihood of HIV-positive adults (15-49 years) accessing antiretroviral therapy due to the distance from their nearest primary healthcare facility. Source: Location, Location: Connecting people faster to HIV services, UNAIDS; Geneva, 2013
US$ Challenges ahead: 3- diverse facility level costs $1,200 Maximum $1,000 $800 US$682 Average $600 $400 Minimum $200 US$136 US$186 US$232 US$278 $0 Malawi Ethiopia Rwanda Zambia RSA South Africa* *Republic of South Africa: costs include updated antiretroviral prices, which were renegotiated by the RSA government in early 2010 and are 53% lower than those observed during the costing period.
Scenario 1: Countries adopt new guidelines for both VL and CD4 Tests (MM) 80 70 60 50 40 30 20 33.7 15.9 38.9 18.6 43.8 21.3 43.6 40.5 37.1 33.4 29.5 25.8 25.2 26.0 25.9 25.5 24.9 24.9 25.7 46.4 10 0 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Global CD4 need Global VL need Source: Clinton Health Access Initiative, 2013 New WHO Guidelines go into effect: Routine VL for ART monitoring 32
Scenario 2: WHO recommends a universal Test and Offer approach Tests (MM) 80 70 60 50 40 30 20 10 0 43.8 38.9 33.7 18.6 15.9 52.5 48.3 43.6 38.5 33.4 29.5 25.8 25.2 26.0 25.9 21.3 22.5 16.1 9.7 3.2 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Global CD4 need Global VL need Source: Clinton Health Access Initiative, 2013 WHO: Test and Offer
Predicted VL scale up will not meet the need 30 25 20 15 10 5 0 47% 51% 45% 32% 38% 23% 28% 2013 2014 2015 2016 2017 2018 2019 Global VLforecast Global VL need Source: Clinton Health Access Initiative, 2013
The share of Lab portfolio varies by country 4% 9% 6% 5% 15% Malawi Ethiopia Rwanda Zambia RSA ARVs Personnel Lab Other Source: ASLM