Too few take a test

Excellent healthcare – locally delivered

Strengthening the treatment cascadeEvidence and practice

Dr Nathan FordTreatment and Care

Department of HIV

Too few take a test

Staveteig et al, DHS Comparative Reports, 2013Global Update on HIV treatment, WHO, 2013

8% - 69% 13% - 76%

37%

Adults

Pregnant women

Substantial attrition between testing and ART initiation

Mugglin et al, Trop Med Int Health 2012

15-30% lost at each step

Still too many people start ART late

The IeDEA and ART cohort collaborations

1 in 4 start ART at CD4<100

Cumulative attrition on ART

Global Update on HIV treatment, WHO, 2013

30% LTF at 3 years

Improving testing and linkage

Suthar et al, Plos Med 2013 [Accepted]Global Update on HIV treatment, WHO, 2013

• Partner and couples testing• Community testing• Self-testing• Combination testing• DBS for early infant diagnosis

Enrollment in pre-ART care

Wynberg et al, 2013 (submitted)Kohler et al, AIDS 2011

Enrollment in pre-ART care

• Earlier initiation• PoC CD4• CTX• Adherence clubs

Wynberg et al, 2013 (submitted)Kohler et al, AIDS 2011

CTX prophylaxis

PoC CD4

Adherence clubs

ART initiation

• Task shifting• Decentralization• Service integration

TB/HIV integration India

Paediatric decentralization in Thailand

PMTCT B+ in MalawiGlobal Update on HIV treatment, WHO, 2013Kredo et al, Cochrane Database of systematic reviews, 2013.

Adherence support

• FDCs• Optimized regimens• Viral load• Adherence support (sms, clubs…)

Fixed-dose combinations

Wilkinson, SAJHIV Med 2013; Ford et al, 2013 (submitted); Butler et al, IAS 2013

Summary

• Successful scale up of ART poses continued challenges to current models of care

• Evidence from research and programmes indicate ways to improve patient care at each step of the cascade

• Future research is needed to identify approaches to enroll people earlier onto ART and support long-term retention in care

WHO’s ongoing workto support ART delivery

• Support to regions for guideline rollout • Future of ART monitoring• Phasing out (d4T) and phasing in (viral load)• Early Infant Diagnosis • Paediatric treatment optimization• Cotrimoxazole prophylaxis• Implementation Science summit

Acknowledgements

Gundo Weiler Eric GoemaereVincent Habiyambere Mathias EggerTxema Garcia-Calleja Andrew BoulleMichel Beusenberg Trevor PeterGottfried Hirnschall Lynne WilkinsonMeg Doherty Hein MaraisCadi Irvine Tony Harries Marco VitoriaBoniface Dongmo NguimfackEyerusalem NegussieRachel BaggaleyNathan Shaffer