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Strengthening the treatment cascade Evidence and practice Dr Nathan Ford Treatment and Care Department of HIV Excellent healthcare – locally delivered Too few take a test 8% - 69% 13% - 76% 37% Adults Pregnant women Staveteig et al, DHS Comparative Reports, 2013 Global Update on HIV treatment, WHO, 2013 Substantial attrition between testing and ART initiation 15-30% lost at each step Mugglin et al, Trop Med Int Health 2012 Still too many people start ART late 1 in 4 start ART at CD4<100 The IeDEA and ART cohort collaborations Cumulative attrition on ART 30% LTF at 3 years Global Update on HIV treatment, WHO, 2013 Improving testing and linkage • • • • • Suthar et al, Plos Med 2013 [Accepted] Global Update on HIV treatment, WHO, 2013 Partner and couples testing Community testing Self-testing Combination testing DBS for early infant diagnosis Enrollment in pre-ART care Adherence clubs CTX prophylaxis PoC CD4 Wynberg et al, 2013 (submitted) Kohler et al, AIDS 2011 • • • • Earlier initiation PoC CD4 CTX Adherence clubs ART initiation Paediatric decentralization in Thailand TB/HIV integration India Global Update on HIV treatment, WHO, 2013 Kredo et al, Cochrane Database of systematic reviews, 2013. • Task shifting • Decentralization • Service integration PMTCT B+ in Malawi Adherence support Fixed-dose combinations • • • • Wilkinson, SAJHIV Med 2013; Ford et al, 2013 (submitted); Butler et al, IAS 2013 FDCs Optimized regimens Viral load Adherence support (sms, clubs…) Summary • Successful scale up of ART poses continued challenges to current models of care • Evidence from research and programmes indicate ways to improve patient care at each step of the cascade • Future research is needed to identify approaches to enroll people earlier onto ART and support long-term retention in care WHO’s ongoing work to support ART delivery • • • • • • • Support to regions for guideline rollout Future of ART monitoring Phasing out (d4T) and phasing in (viral load) Early Infant Diagnosis Paediatric treatment optimization Cotrimoxazole prophylaxis Implementation Science summit Acknowledgements Gundo Weiler Vincent Habiyambere Txema Garcia-Calleja Michel Beusenberg Gottfried Hirnschall Meg Doherty Cadi Irvine Marco Vitoria Boniface Dongmo Nguimfack Eyerusalem Negussie Rachel Baggaley Nathan Shaffer Eric Goemaere Mathias Egger Andrew Boulle Trevor Peter Lynne Wilkinson Hein Marais Tony Harries