Treatment as Prevention and Treatment 2.0 Update UN Forum on AIDS, 24 June 2011 Nicole Seguy, Zhang Lan, WHO.

Treatment as Prevention and Treatment 2.0 Update

UN Forum on AIDS, 24 June 2011

Nicole Seguy, Zhang Lan, WHO

What is TASP?

• Use of ART among HIV-infected individuals to decrease HIV transmission at the population level in order to stop the HIV epidemic

• TASP perspectives:– benefit for the community– benefit versus risk of starting ART earlier for HIV-infected individuals

What do we know, so far?

Mathematical modeling has demonstrated the potential of earlier start of ART for all HIV+ to stop the HIV epidemic

What do we know so far ?

• Viral load is the strongest risk factor for transmission

• ART can lower VL to undetectable levels

• PMTCT offers proof of concept of reduced transmission with ART

• Discordant couple studies are supportive

Discordant couple observational studies

• Rakai cohort study, Uganda (Reynolds S et al. AIDS Feb 2011)

ART provided at CD4< 250

Incidence not on ART: 8.6/100 py

Incidence on ART: 0/25 py• Rwanda and Zambia (Sullivan P,

CROI 2009)

Incidence not on ART: 3.4/100 py

Incidence on ART: 0.7/100 py

What do we know, so far? Individual benefit of starting ART earlier (CD4>350)

• NA-ACCORD observational study:– higher risk of death (mostly related to non-AIDS events) when ART was started

at CD4 <350 compared to > 350

but CASCADE cohort study in Europe has shown little survival benefits of earlier start

More on-going Studies

HPTN 052 Breakthrough

• 12 May 2011 results: “if an HIV-infected person adheres to an effective ART regimen, the risk of transmitting the virus to their uninfected sexual partner can be reduced by 96%”

WHO/ UNAIDS New Recommendations

• Michel Sidibe, May 2011: “Now we need to make sure that couples have the option to choose Treatment for Prevention and have access to it”

• In July 2011, WHO will release a recommendation and guidance on ART for discordant couples– ART for HIV+ in discordant couple irrespective of CD4

count– ART once started should be continued for life– No single method is fully protective– couples should make evidence-informed decisions on

which combination of HIV prevention options is best for them

Remaining Challenges and Obstacles

Awareness of HIV Status and Treatment in China, 2010

中国 HIV感染知晓率与治疗比例， 2010

April 21, 2023 © 2010 Bill & Melinda Gates Foundation | 11

28 % Knew their status

Source: Ray Yip, Gates Foundation

How to Address these Challenges and reach Universal Access to ART by 2015?

Treatment 2.0

Treatment 2.0 Priorities Treatment 2.0 Priorities

TREATMENT2.0

Adapt delivery systems

Mobilize communities

POC and other simplified

monitoring

Optimize drug regimens

Reduce costs

Progress in point of care diagnostics in China point of care diagnostics in China

• Use of rapid HIV test:– New Technical Manual for HIV Rapid Testing– Possibly use of RT by non health staff– Provision of preliminary results ->Pre-qualification of RT (WHO 2011-12) ->Quality assurance / QC systems (US CDC) ->Post market surveillance (WHO)

• Integration of syphilis and HIV RT screening for ANC and possibly MSM– MSM RT training (14-15 June 2011)– MSM guidelines (14 June) ->NCSTD rapid syphilis pilot screening in

outreach SW and MSM services at 2 sites

Progress in Adapting Delivery Systems in China

• Expand HIV testing and counselling (PITC and community-based)

• Strengthen procurement and supply systems: WHO/MSH assessment and SOP

• Continuous Quality Improvement system pilot in 4 provinces• Costing of community based service delivery (AIDS Care China)• Strengthened collaboration between health staff, local CDC and

CBO at some sites (T2.0 pilots)• Draft M&E framework for HTC to treatment cascade at T2.0 pilots

HIV TestingEnrolment into care

pre-ART ART

HIV Care and Treatment Continuum

Loss-to-Follow-Up (LTFU)

Progress in Mobilizing Communities in ChinaProgress in Mobilizing Communities in China

Strengthen demand side for treatment

Community-based testing and counselling

Involvement in design and delivery of treatment programs

Design and delivery of care and support services

Progress in Optimizing Drug Regimens in China

• Revised National Free ART manual using WHO 2010 recommendations:– TDF based regimens for patients co-infected with hepatitis B as a first

step – D4T phase out plan

• Revised National PMTCT Guidelines using 2010 WHO recommendations:– Triple maternal ARV prophylaxis

1st line ARV for adult 2nd line ARV for adult Comments

Current regimen AZT/D4T+3TC+NVP/EFV TDF+3TC+LPV/r National Free ART Manual 2e ed.

New regimen AZT/TDF+3TC+NVP/EFV AZT/TDF+3TC+LPV/r 3rd ART manual in process (end 2011)

Progress and Challenges in reducing Progress and Challenges in reducing Treatment Costs in ChinaTreatment Costs in China

• Services delivery costs:– wider CBO engagement in service delivery to improve adherence and

delay second line (T2.0 pilots: cost saving estimations)• ARV costs:

– Current high ARV drug prices in China– Scenario-based cost reduction analysis for ARV drugs (CHAI, Dec. 2010)– Possibilities to purchase or produce cheaper drugs (including generic

FDC) should be used – China should be able to offer TDF based first line regimen to all patients

ARV Source

China national tender price (USD ppyr)

CHAI ceiling price (USD ppyr, May 2011)

3TC 150 mg GSK +++++ 32AZT 300 mg domestic - 89D4T 30 mg domestic - 24EFV 600 mg Merck ++++++++ 60LPV/R 200/50 mg Abbott + 399NVP 200 mg domestic - 36TDF 300 mg Gilead - 78Combinations Singles Generic FDCAZT/3TC/NVP + 134TDF/3TC/EFV +++++ 169

Thank You