An AIDS-free generation: Hope vs Hype...Trends in the HIV response: 2000 - 2012 Coverage of PMTCT services for pregnant women infected with HIV People living with HIV receiving ART

An AIDS-free generation: Hope vs Hype

Eleanor Gouws-Williams Treatment as Prevention in Africa Botswana, 30 April – 3 May 2014

18.5 million people living with HIV 1.1 million new HIV infections in 2012 750,000 AIDS related deaths in 2012

Eastern and Southern Africa

Outline  

•  Current trends in the provision of ART and PMTCT services

•  The impact of ART and PMTCT services on epidemic trends in the region

•  Some scientific results from this area

•  Conclusions

Trends in the HIV response: 2000 - 2012

Coverage of PMTCT services for pregnant women infected with HIV

People living with HIV receiving ART

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2000 2002 2004 2006 2008 2010 2012

Num

ber  o

f    pe

ople  re

ceiving  AR

T  (M

illions)

0

10

20

30

40

50

60

70

80

90

2000 2002 2004 2006 2008 2010 2012

Wom

en  re

cieiving  PMTCT  service  

(Percent)

Num

ber o

f peo

ple

rece

ivin

g A

RT

(M

illio

ns)

Wom

en re

ceiv

ing

PM

TCT

serv

ices

(P

erce

nt)

AIDS  mortality  

Source: UNAIDS 2013 Global Report

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0

200

400

600

800

1,000

1,200

1,400

1,600

1990 1995 2000 2005 2010 2015

Peop

le  re

ceiving  AR

T  (M

illions)

AIDS

 Mortality  (Tho

usan

ds)

Survival  of  people  on  ART  

0

2

4

6

8

10

12

14

16

18

20

1990 1995 2000 2005 2010 2015

Num

ber  o

f  peo

ple  living  with

 HIV  

(Millions)

Most countries in the region have shown an increase in life expectancy •  In South Africa, life expectancy has increased from 57 years in 2010 to 60 years

in 2012 because of ART expansion •  In an area severely infected with HIV in South Africa, life expectancy increased

by 11.3 years between 2003 and 2011, from 49.2 to 60.5 years because of ART (Bor J, et al. Science 2013)

New child infections in eastern and southern Africa •  PMTCT coverage in 2012: 75% [70 – 82%] •  Estimated number of new child infections has fallen by 65% since its peak

Source: UNAIDS 2013 Global Report

HIV incidence among adults in eastern and southern Africa

•  HIV incidence among adults has fallen by 48% since 2001

•  Modelling studies suggest that new infections in Botswana, Namibia, South Africa and Zimbabwe are between 20 and 50% lower than it would have been in the absence of ART (UNAIDS 2012; Eaton et al. PLoSMed 2012)

Source: UNAIDS 2013 Global Report

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1990 1995 2000 2005 2010 2015

HIV  Incide

nce  am

ong  ad

ults  (%

)

Available evidence suggest that it is possible to substantially reduce HIV transmission through early provision of ART

•  Modelling studies −  Granich et al., Eaton et al.

•  Observational studies

−  Donnell et al., Attia et al.

•  Randomised control trials −  HPTN052

•  Population studies −  Africa Centre in rural KZN

1980 2000 2020 2040

Source: Tanser Science 2013; Willliams 2013

Source: Granich Lancet 2008

0 0 10 20 30 40 50 60 ART coverage

In

cide

nce

rate

ratio

0

0.2

0.4

0.6

0.8

1.0

Inci

denc

e pe

r yea

r

§  Employment prospects improve for patients on ART

(Bor et al. Health Affairs, 2012)

§  People on ART have better work performances because of improved health (Rosen et al. AIDS, 2008)

§  Improved quality of life of those infected with HIV as well as their families

§  Potential to reduce stigma and discrimination

(Roura et al. STI 2009)

Additional benefits of ART

Years since start of treatment Source: Bor et al. Health Affairs 2012; UNAIDS 2012

Generic competition has cut costs

$10,400

$2,700

Lowest generic price, first-line ARV regimen

Originator generic price, first-line ARV regimen

Number of people in LMICs receiving antiretroviral treatment

Source: UNAIDS

Challenges

•  Demand creation −  Proportion of people knowing their HIV status still low (between 10 – 75%

people ever tested for HIV across countries in the region) −  Median CD4 at first enrolment in treatment still low

•  Weak logistic management systems leading to shortage of drugs

•  Health systems and human resource capacity need to be strengthened −  to consider decentralization of care and involvement of communities to

support programmes

•  Lack of adequate treatment programmes for children living with HIV

•  The role of key populations

•  Issues related to human rights, stigma and discrimination

•  Monitoring and evaluation systems

Conclusion Hope for an AIDS free generation

•  Significant progress in scaling up ART and PMTCT services in the last decade

•  Significant reduction in mortality and morbidity •  Significant decline in new infections among children •  Decline in new infections among adults •  Improved quality of life •  Better employment prospects for people infected with HIV •  Most countries have started to implement or have plans to implement

the new WHO treatment guidelines

2000 2013