The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO.

The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact

Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO

Getting to Zero mortality

1. Taking stock: How close is Asia to zero HIV-related deaths?

2. Identifying current bottlenecks and response gaps

3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment

4. Looking ahead: current and future opportunities


1. Taking stock: How close is Asia to zero HIV-related deaths?




Getting to Zero mortalityGetting to Zero mortality

Eastern Mediterranean

Europe South-East Asia and the West-

ern Pacific

Africa The Americas All low- and middle-income

countries

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%2009 2010 2011 2012

51%64%

Proportion of eligible adults living with HIV receiving ART, by region, 2009–2012

Adult ART coverage in Asia is below the global average for low- and middle-income countries

Source: UNAIDS/WHO Coverage: number of adults receiving ART in 2012 / number of adults eligible for ART in 2012 according to 2010 guidelines.

Indonesia

BangladeshNepal

Sri Lanka

Malaysia

Maldives

MyanmarIndia

ASIA

Viet Nam

Philippines

Thailand

Papua New Guinea

Cambodia0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Asia:51%

ART coverage in selected Asian countries, 2012

Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines

Great variability in access to ART in Asia

Source: UNAIDS/WHO

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

GlobalAsia

In Asia: - 650,000 lives saved 2005-2012Yet: - 260,000 died in 2012 alone

30%

20%

Peak: 2005

HIV-related deaths have decreased in Asia, but less than globally (in LMICs)

Source: UNAIDS/WHO

1. Taking stock: How close is Asia to zero-AIDS related deaths?



4. Looking ahead: vision and opportunities for the future


Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam

Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010

In Asia, 1 in 3 patients started ART at CD4<100* in 2010

Still too many people start ART late

Est. number of PLHIV

No. PLHIV diagnosed &

Reported

PLHIV in care (pre-

ART+ART)

PLHIV on ART No. receiving VL

VL suppressed 0

100 000

200 000

300 000

400 000

500 000

600 000

700 000

800 000

900 000100%

50% 42%

22% 16% 13%

Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

Cascade of HIV diagnosis to viral suppression, China, 2012

Too many people are not aware of their HIV status

Cam

bodi

a(2

007/

2011

)

Chin

a (2

012)

Indi

a (2

012)

Mon

golia

(2

012)

Mya

nmar

(200

8/20

09)

Nep

al(2

009/

2011

)

Phili

ppin

es

(201

1)

Thai

land

(2

012)

Viet

Nam

(2

012)

Med

ian

0

10

20

30

40

50

60

70

80People who inject drugsMen who have sex with menFemale sex workers

Key populations: too many unaware of their HIV status

Percentage of key populations who received an HIV test in the last 12 months and know their results

%

52%41%

33%

Source: WHO, 2013

Est. number of PLHIV

PLHIV diagnosed and reported

PLHIV in care (pre-ART+ART)

PLHIV currently receiving ART

No. receiving VL VL suppressed 0

50 000

100 000

150 000

200 000

250 000

300 000 100%

78%

32% 28%

n.a n.a

Too many people are lost to care after diagnosis

Cascade of HIV diagnosis to care, Vietnam, 2012

Sources:

Estimated number of people living with HIV: UNAIDS 2013.

WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

12 months 24 months 60 months 0

10

20

30

40

50

60

70

80

90

100

84%80%

69%MalaysiaCambodiaChinaPapua New GuineaIndonesiaWeighted av-erage

Still too many people are lost from ART: Retention at 12, 24 and 60 months

Still too many people are lost from ART: Retention at 12, 24 and 60 months

%

Source: WHO/UNAIDS

0

10

20

30

40

50

60

70

80

90

100

27

16 19 18 20 1712

36

22 2415

61

31

18

1

51

2215

919

52

17 17

50

36

0

2230

% TDF % d4T

• 44 different first-line regimens• 119 different second-line regimens

• 30% of patients still on d4T• Only 18% of patients on TDF

Source: WHO ARV Use Survey, 2013

Are the optimal regimens being used?

Proportion of d4T and TDF among adult patients on 1st line ART by end of 2012

%

Still too many people who:- do not know their HIV status- start ART late - take sub-optimal regimens- are lost to follow-up- do not have access to comprehensive

package of care services

Important challenges in Asia

Key populations require tailored approaches and service models



3. Towards greater impact: The 2013 Consolidated ARVs Guidelines – earlier, better, and simpler treatment



• Threshold moved to < 500 CD4 (adolescents, adults, MSM, TG, SW, PWID)

• Priority for reaching all HIV+ symptomatic persons and those with CD4 < 350

• CD4-independent situations for ART initiation:– HIV/TB coinfection and HBV advanced liver disease– HIV serodiscordant couples – Pregnancy: “options B/B+”– Children less than 5 years of age

Earlier treatment initiation

Simpler and better treatment: one regimen for all

• Harmonize regimens : Adults, Pregnant Women (1st trimester), Children >10 years, TB and Hepatitis B

• Simplicity: effective, well tolerated, once-daily FDC facilitates adherence

• Streamlines drug procurement and supply chain management

• Affordability: cost declined significantly since 2010

Preferred 1st line regimen: TDF + 3TC (or FTC) + EFV

Viral load is recommended as the preferred monitoring approach to diagnose and confirm ARV treatment failure

If viral load is not routinely available, CD4 count and clinical monitoring should be used to diagnose treatment failure

Improved monitoring of ART Response

Key objective: earlier identification of treatment failure

Expanded HIV testing and counselling

Provider-Initiated Testing and Counselling (PITC)

Community-based testing (June 2013)

HIV Self testing (HIVST) • FDA (USA) approval of OraQuick for HIVST (July 2012)• Evolving approach, particularly relevant for key populations • Legal, ethical, and public health implications

Countries are already moving: CD4 threshold for ART initiation

* As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions

2

13

1

200

350

500

88 200/350

500

Number of countries surveyed: 16

National policies as of August 2013 Likely changes

Countries are already moving: PMTCT – move to option B or B+

* As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions

2

9

5 Option A

Option B

Option B+

610 Option B

Option B+

Number of countries surveyed: 16

National policies as of August 2013 Likely changes

20112012

20132014

20152016

20172018

20192020

20212022

20232024

2025 0

500 000

1 000 000

1 500 000

2 000 000

2010 guidelines 2013 guidelines

Major reduction in mortality expected

Estimated annual HIV-related deaths

-39%

Source: Special analysis conducted by Futures Institute, 2013






The path towards “Zero deaths”

Scale up Innovate Research and develop

Testing and ART to all people

living with HIV

Drugs

DiagnosticsFocus on key populations

Linkages and retention

Comprehensive care models

Service delivery models

Cure

Preventive vaccine



living with HIV

Drugs




Scale up Innovate


Cure

Preventive vaccine

Research and develop

Scale up Innovate Research and develop



living with HIV

Drugs





Cure

Preventive vaccine

Potential strategies to cure HIV

Source: IAS

Conclusions: the way forward

1. Implement new ARV Guidelines: earlier, better, simpler ART

2. Focus on key populations: community-based models for testing; comprehensive care

3.Enhance service quality and integration for broader and sustained impact.

4.Lead Innovation and Increase Investments

Rachel Baggaley, Andrew Ball, Jhoney Barcarolo,Michel Beusenberg, Meg Doherty, Nathan Ford, Vincent Habiyambere, Ying-Ru Lo, Amaya Maw-Naing, Razia Pendse, Jos Perriens, Nathan Shaffer, Marco Vitoria, Gundo Weiler

Acknowledgements

The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO.

Documents

mortality slide

unaidswho slide

simpler art

efv slide

ias slide

preventive vaccine slide

hiv source

art initiation