Transcript Replenishment_2013Session1TIMOTHYHALLETT_Presentation_enx

An Historic Opportunity to
Prevent the Spread of HIV
Timothy Hallett
Imperial College London
Members of The Applied HIV Epidemiology Research Group / HIV Modelling
Consortium:
Sarah-Jane Anderson, Daniela Fecht, Ide Cremin, Ellen McRobie, Britta Jewell,
Jeff Eaton & Nicholas Menzies
Clear evidence for power
of interventions
Falling Costs
An Historic Opportunity to
Prevent the spread of HIV
Experience in Getting Results
Epidemiological Intelligence
Some Downward Trends in New HIV Infections in Some Countries…
Global
Sub-Saharan Africa
4,000,000
4,000,000
New HIV Infections
New HIV Infections
5,000,000
3,000,000
2,000,000
1,000,000
-
3,000,000
2,000,000
1,000,000
-
1990
1995
2000
2005
2010
2015
1990
1995
2000
2005
2010
2015
… Set Against a Backdrop of HIV Increasing (by 353%) Share of Global Disease Burden
Source: UNAIDS Estimates (www.unaids.org) & Global Burden of Disease 2010 (http://www.healthmetricsandevaluation.org/) (Lozano et al, Lancet 2012)
Clear evidence for power
of interventions
There have been several major
breakthroughs for the prevention of HIV
through sexual transmission.
The Cost of ARV Regimens Reduced by
Up to 70%
ARV Drug Cost - All Regimems
Falling Costs
ARV Drug Cost - Preferred Regimens
$300
$600
$250
$200
$400
$150
$100
$50
$200
63% decline since 2003
70% decline since 2007
$0
1995
$0
2000
2005
2010
2015
1995
2000
2005
Region: Sub-Saharan Africa
Preferred Regimens = Efavirenz (EFV) + Emtricitabine (FTC) + Tenofovir (TDF); Efavirenz (EFV) + Lamivudine (3TC) + Tenofovir (TDF).
Source: WHO Price Reporting Mechanism (http://apps.who.int/hiv/amds/price/hdd/)
2010
2015
The Costs of Delivering ART have Dropped by 11% per year
for the Last Decade
11% annual decline
These plots show the estimated non-drug average cost per-patient year of ART for adults. The estimates
control for differences in the countries from which the data were collected.
Source: Nicolas Menzies, Harvard Center for Health Decision Science.
Achieving High Rates of HIV Testing
Mode of HIV Testing
% population HIV tested
House-to-House Testing
94% coverage in one round
Community
Mobilization
x4 – x8 increase in testing
over 3 years.
Provider-initiated
testing
~50% after one year
Source: Tumwesigye AIDS Patient Care and STDs 2010 ;Sweat et al., Lancet ID
2011; Weiser et al, PLoS Med 2006
HIV Prevention in Specific Populations
Experience in Getting Results
HIV Transmission Between
Long-term Sexual Partners
10
Reduced HIV
Transmission due to
counseling and
facilitated disclosure.
8
6
4
2
0
Rakai
Partners HSV Partners PrEP
HPTN 052
A Hypothetical Scenario: What Would Happen The
Totality of Spending on HIV Was Frozen or Cut?
Zambia
150
300
+400,000 deaths
250
Cut
100
Frozen
Expanded
50
-400,000 new infections
Total adult deaths (1000s)
New HIV infections (thousands)
+700,000 new infections
Frozen
200
150
Cut
Expanded
-200,000 new infections
100
50
0
0
2010
2015
2020
2025
2030
2010
2015
2020
2025
Cut: The ART program is discontinued.
Frozen: No need persons are initiated on ART.
Expanded: Zambia achieving 80% ART coverage with eligibility at CD4<500.
Red line: is "business as usual" -- same policy (350) in place and same patterns of testing/linkage.
Source: Cori, Fraser et al., Forthcoming
2030
The Investment Framework has Promoted A Carefully Prioritized
Approach…
CRITICAL
ENABLERS
Social enablers
• Political commitment &
advocacy
• Laws, policies &
practices
• Community
mobilization
• Stigma reduction
• Mass media
BASIC PROGRAMME ACTIVITIES
Programs
for key
populations
Behaviour
Change
Progr.
PMTCT
Stopping new
infections
Condoms
Programme enablers
• Community-centered
design & delivery
• Programme
communication
• Management & incentives
• Operations Research
OBJECTIVES
Keeping
people alive
Treatment
Male
circumcision
SYNERGIES WITH DEVELOPMENT SECTORS
Social protection; Education; Legal Reform; Gender equality; Poverty reduction; Gender-based violence;
Health systems (incl. treatment of STIs, blood safety); Community systems; Employer practices.
Source: UNAIDS
The Investment Framework has Promoted A Carefully Prioritized
Approach…
Source: UNAIDS
Geographic and Epidemiological Data Can Now Be Triangulated
to Identify Foci of HIV Transmission
Kenya
Average Risk of HIV
infection for a “low risk
women” estimated to vary
10-fold between counties.
Epidemiological Intelligence
Prioritizing Resources To Those Foci Can Radically Improve
Efficiency, Generating More Health For the Same Budget
The Specific Example of Kenya
No Additional HIV
Prevention Spending
Usual Prioritization Strategy
+ Prioritizing Epidemic Foci
21% increase in HIV
infections averted
Note: Assumes buudget of $600M and uniform across locations.
& Marginal cost per infection averted
of new technologies reduced by 66%.
With finer scale data even greater impact may be possible.
Variation by AGE in populations
Distribution of New HIV Infections
Variation WITHIN a Small District
Men
Age group
5.7% of study area.
1 in 3 new HIV infections
Women
Age group
> 50% of infections occur among men
and women aged < 25 years
Source: Tanser et al., CROI 2011 (http://www.retroconference.org/2011/Abstracts/41395.htm) & Stover et al., STI 2010
… And Moves The Epidemic Towards a Tipping Point, at which a
Foreseeable Vaccine Could Effectively Terminate Epidemics
+ Vaccine
Clear evidence for power
of interventions
Falling Costs
An Historic Opportunity to
Prevent the spread of HIV
Experience in Getting Results
Epidemiological Intelligence