WHO Target 90-90-90 : Achievable for Latin Americaregist2.virology-education.com/2017/andWorkshop/02_Afani.pdfRef: The Joint United Nations Programme on HIV/AIDS. 9090- -90 An ambitious

WHO Target 90-90-90 : Achievable for Latin America

Dr. Alejandro Afani MD, FACPProfesor Titular

Director Centro de VIHHospital Clínico U. de Chile

Speaker bureau of Gilead, ViiV, BMS, MSD, Janssen, Abbvie

Participating in Boards on HIV

Participation in clinical research: BMS, ViiV, MSD

Sida Chile and Latin American Workshop

Support from ViiV, Gador, BMS, Janssen, MSD, Abbvie

Disclousure

In 2000, 191 countries around the world sign The UnitedNations Millennium Declaration = 8 InternationalMillennium Development Goals were established.

Target 6 = “Have halted by 2015, and begun to reversethe spread of HIV/AIDS”

Millennium Development Goals Report, UNAIDS, 2015

Many advances have been achieved since then andthe pandemic appears to be in retreat.

However only 45% of people with HIV in the

world knows their status.

Resumen de la Epidemia VIH/SIDA al año 2015

Región Número Estimado de

Personas que Viven con VIH

Número Estimado de

Nuevas Infecciones

en 2015

Prevalencia Estimada en

Adultos

Número Estimado de Defunciones por SIDA en

2013Mundo 36,7 millones 2,5 millones 0,8% 1,2 millones

América Latina

1,7 millones 90.000 0,4% 41.000

Chile 39.128 2.555 0,3-0,4% -----

Fuente: Estimaciones Programa Conjunto de Naciones Unidas para el SIDA-ONUSIDA. 2014

Country n centers n patients(06/16 paper)

1 Argentina 6 9.091

2 Chile 11 17.074

3 Colombia 10 17.749

4 Costa Rica 2 2.883

5 Ecuador 5 13.035

6 México 2 18.341

7 Panamá 1 2.468

8 Paraguay 1 844

9 Perú 3 14.693

10 R. Dominicana 2 1.670

11 Venezuela 1 1.692

Total 44 99.540

A Junio 16

Country n centers n patients1 Argentina 14 11.8832 Chile 11 16.8463 Colombia 18 24.7984 Costa Rica 2 2.3065 Ecuador 5 11.4916 Guatemala 1 4.2077 México 4 22.1628 Pánama 2 2.6599 Paraguay 1 0

10 Perú 4 13.32811 Republica Dominicana 2 81112 Venezuela 4 3.682

Total 68 114.173

A Junio 17

> 50 años en control en Latinoamérica

Distribución de casos activos según edad.Centros seleccionados de atención de pacientes

VIH de Latino América. 2013-2014

21,5%> 50 y/o

21,7%

43,9%

22,9%

8,6%

2,6%0,4%

26,1%

36,6%

24,8%

9,1%

3,0%0,4%

36,4%

32,1%

19,2%

9,3%

2,5%0,6%

0%

10%

20%

30%

40%

50%

15-29 30-39 40-49 50-59 60-69 > 70

2001-2005

2006-2010

2011-2015

Distribución por edad casos nuevos en Chile3 quinquenios

0

1000

2000

3000

4000

5000

15-19 20-29 30-39 40-49 >50

1999-2003 2004-2008 2009-2013

125,4% 113,0% 38,5% 94,9% 90,0%

Nuevos casos 1999 – 2013 por edad

-10,0%

10,0%

30,0%

50,0%

70,0%

90,0%

110,0%

15-19 20-29 30-39 40-49 >50

25,9%

5,8% -9,0%

26,5%14,2%

79,0% 101,3%

52,2% 54,0%66,4%

99-03 a 04-08 04-08 a 09-13 99-03 a 09-13

Tasa de aumento por edad

Nuevos casos 2013 – 2015 L Am:aumento en jóvenes

4,8%

15,9%

19,3%

26,5%

18,3%

9,0%

2,9% 0,7%

5,8%

12,4%14,4%

27,7%

19,5%

11,0%

2,9%

0,6%0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

15-19 20-24 25-29 30-39 40-49 50-59 60-69 >69

Hombres

Mujeres

n= 17.988n= 30 centrosCountries= 82013-2015

40,0%; 32,6%

24,3%22,6%

31,2%36,8%

42,5%42,2%

51,3%

47,2%

25,4%25,7% 26,3% 24,8% 24,2% 26,8%

24,2%

24,2%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

15-19 20-24 25-29 30-39 40-49 50-59 60-69 >69

<200

200-349

350-499

>499

Beltran C, et al. HIV Hepatitis Americas Brazil 2017. P042

Presentación tardía por edad en Latinoamérica

90-90-90: 2020 targets to control HIV-AIDS in Latin America and Caribbean

90 % of people living with HIV

diagnosed

90 % of the diagnosedpeople on ART

90% of those on ART with viral

suppression

Fourth goalReducing late diagnosis (<200 CD4 cells/mm3) below 10%

among newly diagnosed individuals

First Latin American and Caribbean Forum on the Continuum of Care , Mexico, 2014

UNAIDS 90-90-90: HIV Treatment Targets for 2020 with Global Estimates (2014)

Ref: The Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014; JC2684 (Numbers as of March 2015) How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015.

Target 1: 90% of HIV+ people diagnosed

Target 2: 90% of diagnosed people on ART

Target 3:90% of people on ART with HIV RNA suppression

90%81%

73%

0%

20%

40%

60%

80%

100%

HIV Positive People Diagnosed On ART Viral Suppression

36.9million 33.2

million 29.5million 26.9

million

53%41%

32%*

0%

20%

40%

60%

80%

100%

HIV Positive People Diagnosed On ART Viral Suppression <1000(ITT)*

36.9million

19.8million 15.0

million 11.6*million

Global Estimates (2014-15) vs the Gap to reach 90-90-90 Targets

Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015. * Average viral suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review." Bulletin of the World Health Organization 91.5 (2013): 377-385.

Breakpoint 1:13.4 million

Undiagnosed Breakpoint 2: 14.9 million not treated

Breakpoint 3: 15.3 millionNot Virally Supressed

Target 1 versus Target 2:Rates of diagnosis and those diagnosed on

treatment, by country

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Perc

ent o

f dia

gnos

ed p

eopl

e on

ART

Georgia

NetherlandsAverage of

30* Sub-Saharan African countries

Estonia

USA

BrazilBritish Columbia

(Canada)

France

Russia

Denmark

U.KingdomAustralia

Switzerland

UNAIDS 90-90-90 Target 1

Ukraine

Colombia

Cuba

Kyrgyzstan

Vietnam

Rwanda

UNAIDS 90-90-90 Target 2

Percentage of all HIV + people diagnosed*30 countries with data on GAPRP and DHS data, 2008 - 2014 (How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 lessons of hope from the AIDS response July 2015

Cascade of HIV care – Switzerland 2012

81% 80% 79%71% 68%

0%

20%

40%

60%

80%

100%

HIV Positive People Diagnosed Linked to care Retained in Care On ART Viral Supression <200copies/ml

12,700 12,300

10,70011,200

15,700

12,600

Ref: Kohler P, Schmidt JA, Ledergerber B, Vernazza LP. Estimates of HIV prevalence, proportion of diagnosed patients and quality of treatment in Switzerland. 2014.

Breakpoint 1

Breakpoint 2

Cascade of HIV care – Russia 2013

Ref: Pokrovskaya, A., et al The cascade of HIV care in Russia, 2011–2013. Journal of the International AIDS Society 2014;17(4). http://www ncbi nlm nih gov/pmc/articles/PMC4224814/pdf/JIAS 17 19506 pdf

49%

38% 35%

12% 9%

0%

20%

40%

60%

80%

100%

HIV Positive People Diagnosed Linked to care Retained in Care On ART <1000 copiesUndetectable HIV RNA

1,363,330

515,403481,783

156,858 127,054

668,032

Breakpoint 1

Breakpoint 2

Breakpoint 3

78% 78%72% 70% 70% 68% 67% 66% 64% 63% 62%

59% 58%54% 53% 52% 52% 52% 51% 50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Prop

ortio

n of

peo

ple

livin

g w

ith H

IV

with

vira

l sup

pres

sion

Países con reportes de más del 50% de supresión virológica (2010-2016)

73%

Kindly provided by Dr. I. Prudente

Sweden the first country to achieve UNAIDS/WHO 90-90-90 targetMichael Carter Published: 14 September 2016

Sweden has become the first country to achieve the UNAIDS/World Health Organization (WHO) 90-90-90 target, research published in HIV Medicine. At the end of 2015, 90% of HIV cases in Sweden were diagnosed, 99.8% of people were linked to care and 95% of people taking ARV for at least 6 months had a viral load below 50 copies/ml.

“We believe that Sweden is the first country to achieve the UNAIDS/WHO 90-90-90 goal,” comment the investigators.

Elementos de Análisis

• Se reconoce un país en el mundo que cumple la meta OMS 90-90-90, con un 73% de personas VIH+ con CV indetectable.

• Gran disparidad y heterogeneidad entre países y dentro de un mismo país.

• Todos los países de Europa Occidental han logrado supresiónviral por sobre >50% de personas VIH+

• Diagnóstico constituye el principal breakpoint globalmente

UNAIDS 2014

Características en Latinoamérica

Heterogénea

60% hombres

Epidemias concentradas en varios países(HSH=15%–20%,mujeres transgénero=16%-32%).

35-40% diagnóstico tardío

UNAIDS report on the global AIDS epidemic 2013. UNAIDS. The Gap Report. No one left behind. 2014.Crabtree-Ramirez B et al. PloS One 2011;6:e20272.

Source: UNAIDS special analysis, 2016

1 2015 measure derived from data reported by 15 countries, which accounted for 76% of people living with HIV in the region. 2 2015 measure derived from data reported by 21 countries. Regionally, 77% of all people on antiretroviral therapy were

reported to have received a viral load test during the reporting period.

Porcentaje de PVV que conoce su diagnostico

Porcentaje de PVV en tratamiento ARV

Porcentaje de PVV con carga viral indetectable

Progreso hacía las metas 90 90 90, América Latina y el Caribe, 2015

Kindly provided by Dr. G. Ravasi

0102030405060708090

100

VIH (+) Dgtco Atendidos En TAR < LDE

100%

69%

54%58%49%

41.681 diagnosticados 34.690 vinculados a atención32.788 en TAR29.628 suprimidos

90 90 90 en Chile 2017A diciembre 2016

Casos confirmados oficialesChile, 2010 - 2015.

BOLETÍN VIGILANCIA DE LABORATORIOVOL. 6, NO. 11, NOVIEMBRE 2016

Cuáles son nuestros objetivos de diagnóstico hoy?

Programa que identifique a la mayor cantidad de personas en estadíos tempranos de la infección y que los vincule con servicios de salud y tratamiento.

Los países necesitan determinar cuál es su mejor estrategia, identificando los servicios de testeo costo-efectivos de mayor alcance a sus poblaciones de riesgo.

Tratamiento antirretroviral en Latinoamérica (2000-2016)

682259

805212

958711

> 1M

42

48

5659

6

1819

6

0

10

20

30

40

50

60

70

80

90

100

0

200.000

400.000

600.000

800.000

1.000.000

1.200.000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Total en TAR Cobertura TAR (total PVV) incremento % (año anterior)

Fuente: ONUSIDA GAM (2001-2017). 2016 datos preliminares.Nota: no incluye datos de Cuba y Republica Dominicana.

N. P

erso

nas

en T

AR

Porc

entu

al (%

)

Kindly provided by Dr. G. Ravasi

87,4%

89,6%

90,0%

91,1%

96,1%

97,5%

88,6%

96,1%

94,8%

88,3%

50%

60%

70%

80%

90%

100%

110%

120%

Arge

ntin

a

Chile

Colo

mbi

a

Cost

a-Ri

ca

Ecua

dor

Mex

ico

Pana

ma

Peru

Rep.

-Dom

.

Vene

zuel

a

% de pacientes en TAR en Latinoamérica

N= 58,280 patients

Unpublished data from the Latin American Workshop Study Group

Results: ART initiation during 1st year follow up

− 74.6 % of 5,681 pts linked to care during 2013-4 started ART during the 1st year.− Significant heterogeneity within countries was observed.− Argentina, México and Dominican Rep. showed the highest rates of ART initiation

(over 90%) while the other countries had ART initiation rates between 60 and 75%.

Figure 2. Percentage of admitted patients that started ART at the first year of follow up, by country

N patients = 5,681N centres = 22N countries = 7

97 96 9591 89 87 84 84 82 81 80 78 78 77 77 77 75 74

0

10

20

30

40

50

60

70

80

90

100

Retención en TAR a 12 meses, Latinoamérica (2016)

% d

e pe

rson

as

Fuente: ONUSIDA, GAM 2017. Datos preliminares

% retención en TAR (12 meses)

Cascada de atención en Latinoamérica

2,000,000 > 1 M

55%

2015 - 2016

41%

75%

Testeo

VinculaciónInicio de TARRetención en TAR

91%

84% 82%77%

71% 70% 69%

61%58% 57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Brazil Mexico El Salvador Honduras Bolivia Colombia Paraguay DominicanRepublic

(the)

Cuba Nicaragua

Carga viral suprimida en personas en TAR, Latinoamérica (2016)

% d

e pe

rson

as e

n TA

R

Fuente: ONUSIDA, GAM 2017. Datos preliminares

Distribución por backbone

39,7%

25,2%

32,8%

1,8%

0%

10%

20%

30%

40%

50%

60%

TDF-xTC ABC-3TC ZDV-3TC Other

Backbone

N patients = 6,007Centres 25; Countries 8

• 32,8% of patients initiating first ART with ZDV containing regimens• TDF use in first line regimens ranges from less 25% to more than 90%

Distribución por 3a droga

• EFV is the preferred 3rd drug followed by PI/r.• Differences in EFV use observed among countries (40 to 90%)• Very low rates of Raltegravir use as first line ARV in Latin America

62,0%

28,7%

4,1% 4,5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

TDF-xTC-EFV/2NRT-EFV

2NRTI/ATVr -2NRTI/LPVr

2NRTI/RAL 2NRTI/Other3th Drug

N patients = 6,410N centres = 28N countries = 7

• De acuerdo a ONUSIDA, 75% de personas diagnosticadas y 55% en TAR

• A pesar de la heterogeneidad en las guías locales para iniciode TAR, cerca del 90% de los pacientes en control está en terapia (75% inició durante el primer año)

• Tasas de retención adecuadas reportadas en la región >80%• Supresión virológica cerca del 90% a 1 año aún con < 50

copias/ml• El aumento en los recursos para cuidados del VIH son el

desafío de la implementación meta sanitaria OMS 909090

En Latinoamérica

INI TDF/FTC + RAL (TAF) TAF/FTC + RAL TDF/FTC + RAL

TDF/FTC/EVG/c (TAF) TAF/FTC/EVG/c TDF/FTC/EVG/c

TDF/FTC + DTG (TAF) TAF/FTC + DTG TDF/FTC + DTG

ABC/3TC/DTG ABC/3TC/DTG ABC/3TC/DTG

bPI TDF/FTC + DRV/ r (TAF)

TDF/FTC + DRV/ r

NNRTI TDF/FTC/RPV TDF+FTC(3TC)+EFV

Esquemas Recomendados de Inicio a 2017

Country Backbone 3rd drug

ARGENTINA 2016 TDF/3TC or FTC EFV; ATV/r, DRV/rUnder evaluation RAL, EVG, DTG

BRAZIL 2016 ABC/3TCTDF/3TC

EFVDTG, RAL

CHILE 2013AZT/3TCABC/3TC

TDF/FTC or 3TC

EFV; ATV/r, LPV/r, DRV/rRAL

Under evaluation EVG y DTG

COLOMBIA 2016 TDF/FTCABC/3TC

EFV; ATV/r, DRV/rRAL

ECUADOR TDF/FTC EFV

MEXICO 2016 TDF/FTCABC/3TC

EFV; ATV/rRAL

PERUAZT/3TCABC/3TC

TDF/FTC or 3TCEFV

URUGUAY 2014 AZT/3TCUnder evaluation TDF/FTC y ABC/3TC

EFV; LPV/r, ATV/rUnder evaluation DTG

VENEZUELA 2014 TDF/FTC EFVATV/r

Kindly provided by Dra. I. Cassetti (modified)

Guías de Tratamiento Antirretroviral en Latinoamérica

Estándares Latinoamericanos de Diagnóstico, Atención y

TratamientoLANZAMIENTO API Panamá Mayo

2017

Escenario 1ª Línea Alternativa No recomendado

Recom. general(TDF o TAF)/FTC o

ABC/3TC + INIs o EFV o RPV o ATV/r o DRV/r

AZT, ddi, d4T, NVP

Presentacióntardía

EFV, DTG, RAL, EVG/c/TDF/FTC DRV/r Otros IP/r

Embarazo ABC/3TC o TDF/FTC ó 3TC + ATV/r o DRV/r o RAL

AZT/3TC + LPV/r o EFV o RPV

Mujer TDF/ FTC+EVG/c, ABC/3TC+DTG

ATV/r o ATV/c; DRV/r o DRV/c EFV

> 50 años INI, ATV/r, DRV/r, RPV EFV

Coinfección TB TDF/FTC o ABC/3TC + EFV o RAL

Coinfección HepB

TDF/FTC, TDF/3TC o TAF/FTC NVP

Coinfección HepC

RAL ó DTG NVP

Escenario 1ª Línea Alternativa No recomendado

Enfermedadrenal

ABC + 3TC, RAL DTG, DRV/r TDF y coformulacionesfijas; LPV/r, ATV

Riesgo CV alto TDF/FTC + RAL o DTG o RPV ABC, EVG/Cobi, IP/r

Dislipidemias RPV/TDF/FTC o RAL o DTG EFV, IP/r, coform Cobi

Alter.neurocogn.

Incierto: INIs, DRV/r, ABC/3TC? EFV, RPV

Cáncer Individualizar (DDI, EfAdv, etc.)