WHO s regional strategies: HIV, STI and Viral Hepatitis Dr Po-Lin Chan HIV, STI and Hepatitis unit Division of Communicable Diseases WHO APACC Hong Kong, 28-30 June 2018 1
Outline Overview of the HIV, STI and Hepatitis burden Translating global strategies to region and countries Thinking out of the box concurrently with incremental progress The exercise of integration in the Universal Health Coverage (UHC) era 2
We know how to end AIDS - Nittaya Phanuphak, David Cooper Memorial Lecture APACC Hong Kong 2018 & STIs & Viral Hepatitis 3
WHO global health sector strategies Universal Health Coverage Costed actions SDGs Goals and Vision Common structure Cascade of services 4
Major threat: 357 million new cases of four curable STIs in 2012: Chlamydia, gonorrhea, syphilis, trichomoniasis STI > 1 million new cases of STI a day Source: WHO. Global incidence and prevalence of selected curable sexually transmitted infections - WHO Report of Global STI 2015 2012.
The threat of antimicrobial resistance Gonococcal Antimicrobial Surveillance Programme (GASP) Countries with documented elevated minimum inhibitory concentrations to cefixime and/or ceftriaxone, 2009 2013 MIC, minimum inhibitory concentration 6
People living with HIV by WHO region (2016) 7
HEPATITIS / HIV CO-INFECTIONS Global: Of the 36.7 million with HIV - 2.3 million are anti-hcv + - 2.7 million are HBsAg + Prevalence of HIV-HCV coinfection 6.4 4.0 82.4 8 Sources Easterbrook, IAS conference, 2015 (HBV); Platt, Lancet Infect Dis, 2016 (HCV), and a slide courtesy of Dr Jürgen Rockstroh
Estimated Global Number of Deaths from Hepatitis, HIV, Malaria and TB, 2000-2015 Hepatitis 1.34 million Deaths [96% due to HBV/HCV] 9 Source: WHO Global Health Estimates
The Asia and Pacific Region have a large burden of chronic hepatitis ~60% of the global 257 million people living with hepatitis B ~34% of the global 71 million people living with hepatitis C : 40% of the global burden for HBV and HCV (highest in the world) 10 Source : WHO Global Hepatitis Report 2017
SEAR has 30.5% of all global hepatitis related deaths WPR has 33.3% of all global hepatitis related deaths 11 WHO Global Health Estimates 2015
Regional Committee Resolutions: Hepatitis WPR/RC68.R2 triple emtct of HIV, syphilis and HBV endorsed WPR/RC56.R8: Reduce HBsAg prevalence to <2% by 2012 WPR/RC54.R3: Hepatitis B set as an EPI pillar WPR/RC66.R1: Endorse Regional Action Plan for Viral Hepatitis 2016-2020 WPR/RC64.R5: Reduce HBsAg prevalence to <1% by 2017 30 of 36 countries reach <2% goal <1% regional goal of WPR/ RC64.R5 met 2003 2005 2012 2013 2015 2016 2017 12
Regional Framework for Triple Elimination of Mother-to-Child Transmission (EMTCT) of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018-2030 HIV 50 new paediatric HIV infections per 100 000 live births; transmission rate of < 5% (breastfeeding) or < 2% (non-breastfeeding) by 2020 Syphilis 50 cases congenital syphilis per 100 000 live births by 2030 Hepatitis B 0.1% prevalence of HBsAg among children by 2030 13
The triple elimination of mother-to-child transmission of HIV, syphilis and Hepatitis B: Western Pacific regional framework Test: HIV, syphilis, HBsAg If negative then HepB-1 Within 24 hours PNC- 1 PNC- 2 HepB-2 PNC- 3 HepB-3 more than 4 weeks apart from last dose 8+ antenatal visits 48 hr 1-2 wk Wk 6 EPI schedule If HIV and/or syphilis + ve: TREAT If HBsAg+ Maternal, neonatal and child health (MNCH) care platform Set of ADDITIONAL interventions, depending on local context of country - including MOTHER: Categorise MTCT risk (HBeAg; HBV DNA) and assess liver disease status/function; consider use of antiviral drugs in high HBV viral load women; offer testing to partner (and/or household/family), link to hepatitis care services and follow-up INFANT: use of HBIg at birth, post vaccination serological testing (PVST) 1-2 months after last dose of HBV vaccine; re-vaccination if necessary LINK TO: Clinical care pathway for mother and infants who are infected 14
Significant progress made in hepatitis B control through vaccination Verified (18) Serosurvey planned or ongoing (7) Programme improvements required (5) Serosurvey completed and awaiting results (3) Ready for verification (2) Universal HepB3 vaccination started in 2016 (1) Data not available (1) 18 of 37 countries + areas and the WP Region as a whole have been verified to have reached the target of < 1% HBV in children five years of age 15
Incremental approach to prevention of HBV infection at birth and in the first years of life The interventions at the base of the pyramid benefit to the largest number and are necessary for those at the top of the pyramid to be effective Opportunities and challenges Anti-viral treatment can make a difference for the few women with high viral load. HBIg is recommended in many high income countries, but there are supply issues (quantity, quality ) in middle and low income countries. A strong system to test and link to care is the foundation of more interventions. it also allows impact monitoring. Universal administration of a timely birth dose is the first line of defence against perinatal infection for all infants. Three-dose is the foundation to reduce incidence and ensure effectiveness of interventions at birth. 16
Countries are in different stages of implementation of the Regional Viral Hepatitis Action Plan 2016-2020 National plans Available - 11 In developm ent /draft - 4 Countries Australia, China, Japan, Kiribati, Malaysia, Mongolia, New Zealand, Singapore, Vanuatu, Viet Nam, Wallis and Futuna Fiji, Republic of Korea, Palau, Philippines Country HBV HCV Disease burden estimates Economic/budget analysis Disease burden estimates Cambodia Ongoing Ongoing Ongoing Ongoing China Fiji Kiribati Ongoing (update) Complet ed Complet ed Completed Ongoing (subnational) Completed N/A N/A Completed N/A N/A Economic/budget analysis Completed Mongolia Initiating Initiating Completed Completed Papua New Guinea Ongoing Ongoing Ongoing Ongoing Initial discussions and baseline missions (tbc): Cambodia, Papua New Guinea, Solomon Islands, FSM, Tonga, Samoa Philippines Finalizing Finalizing Finalizing Finalizing Viet Nam Finalizing Finalizing Finalizing Finalizing Critical factors: know your epidemic, evidence-based decision making, national commitment with governance structures and action plans 17 WPRO June 2018, provisional analysis
Sustainable financing of HBV and HCV treatment, June 2018 Covered by health insurance or government financing Out of pocket payments 18 WPRO June 2018, provisional analysis
INTEGRATE : pragmatic approaches to supporting scaling up hepatitis testing and treatment services adaptation of WHO 2017 testing guidelines to implementation Programs/services HIV programming: key populations, HIV-co-infected Health services: general public, services for elderly MCH/PMTCT programs Community, mobile, campaign testing Blood Banks Strategic approach: integration & amplification Integration into current programming Integration through expansion of service delivery Triple elimination of HIV, Hepatitis B and syphilis + HCV Integrate and apply as appropriate Implement the WHO guidelines: call back infected donors for counseling and referrals Focus on Guidelines, access to testing and treatment, civil society engagement to expand from HIV to including hepatitis, IEC Integration into existing services eg NCD clinics, health screening programs for elderly, minimum essential package of primary care Universal coverage in pregnant women, index case tracing & family continuum of testing and care Leverage existing HIV CSO networks, country-led strategies Connection to care for those detected positive Need to fit into country-specific context, health systems, financing, current 19 health systems reforms, access to affordable medicines, civil society strengths
16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 - HCV Treatment Cascade, WPRO 2017 13,665,000 Viremic Infections 3,122,000 311,000 223,000 Diagnosed Treated Cured HCV (2017) 23% diagnosed 2.3% received treatment (of all PLHCV) 120,000,000 100,000,000 80,000,000 60,000,000 40,000,000 20,000,000 - HBV Treatment Cascade, WPRO 2016 108,672,000 HBsAgpositive infections 40,454,000 Treatment eligible 20,268,000 Diagnosed 3,918,000 On antiviral treatment HBV (2016) 37% eligible for treatment 50% diagnosed (of those eligible) 19% on antiviral treatment 20 Razavi et al. CDA Foundation. WPRO treatment cascades for HBV and HCV, 18 June 2018
Towards UHC. Service delivery, including integrated decentralised care and treatment to primary level HIV/syphilis/Hepatitis Know your status -General public -At risk eg. age, risk behaviour $$ Financing HIV/hepatitis chronic care & its sequalae 21
And what about advocacy, stigma and discrimination and communications? GENERATE EVIDENCE STRATEGIC COMMUNICATIONS WITH SOCOs For the different audiences Communications plan 2018-2019 22
Summary We have the tools and we know how to get it done UHC is not rocket science but we need to find solutions to the challenges of health systems, people and money Implementation of the health agenda and for HIV, STI and Hepatitis response will need all of us together - breaking the silos, partnerships, networking and multisectoral collaboration 23
The HIV/Hepatitis/STI WPRO team Qiong Cao, intern Takeshi Nishijima, Special Fellow (STI) Donghyok Kwon, Technical Officer, Laboratory Linh-Vi Le, Technical Officer, Strategic information Po-Lin Chan, Medical Officer (Hepatitis) Naoko Ishikawa, Coordinator 24