Transcript From "3 by 5" to Universal Access Kevin M. De Cock Director, HIV/AIDS Department.

From "3 by 5" to Universal Access
Kevin M. De Cock
Director, HIV/AIDS Department
25 Years of AIDS
Epidemiologic Notes and Reports:
Pneumocystis Pneumonia --- Los Angeles
In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed
Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5
patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal
infection. Case reports of these patients follow.
10 Years of HAART
From "3 by 5" to Universal Access:
outline

Current status of HIV/AIDS treatment
in the world

Role of the health sector in working
towards universal access

Conclusions
Dr LEE Jong-Wook
1945-2006
Antiretroviral therapy coverage in low- and
middle-income countries, June 2006
Geographical region
Number of people
receiving ARV
therapy
Estimated need
Coverage
1 040 000
4 600 000
23%
Latin America and the
Caribbean
345 000
460 000
75%
East, South and South-East
Asia
235 000
1 440 000
16%
24 000
190 000
13%
4 000
75 000
5%
1 650 000
6 800 000
24%
Sub-Saharan Africa
Europe and Central Asia
North Africa and the Middle
East
Total
20 low- and middle-income countries in sub-Saharan Africa, Asia,
Latin America and the Caribbean treated more than 50% of those
in need, June 2006
ARV Therapy: global need, June 2006
(Number of people in millions)
5
70% of the total unmet need
4
Unmet need
Receiving ARV therapy
3
2
1
Sub-Saharan Latin America and
the Caribbean
Africa
East, South and
South-East Asia
Europe and
Central Asia
North Africa and
the Middle East
Women's access to HIV treatment, June 2006
Mozambique
Uganda
Nigeria
Malawi
Zimbabwe
Zambia
Central African Republic
Botswana
Kenya
Côte d'Ivoire
Namibia
Rwanda
United Republic of Tanzania
Burundi
South Africa
10%
20%
Percentage of adults on ART who are women
30%
40%
50%
60%
70%
Percentage of HIV-infected persons who are women
Children's access to HIV treatment, June
2006
Africa
Latin America
Asia
Median: 8%
Median: 8%
Median: 5 %
Access to PMTCT services in sub-Saharan
Africa, 2005
80
70
60
(Percentage coverage)
50
40
30
20
10
Percentage of HIV-infected pregnant women
Togo
receiving ARV prophylaxis for PMTCT
Namibia
Zambia
Guinea Bissau
Benin
Central African Republic
Swaziland
Burundi
Uganda
Gabon
Rwanda
Kenya
Zimbabwe
Lesotho
Mozambique
Côte d'Ivoire
Treatment access among IDU in Eastern
Europe
IDU as % of people living with HIV
100
IDU as % of people on ART
90
80
70
60
50
40
30
20
10
Moldova
Estonia
Ukraine
Serbia Lithuania
and
Montenegro
Croatia
Czech
Russian
Federation Republic
Equity of treatment access
– knowledge gaps
Coverage and quality of care in:
 Time
 Place
 Person
Estimated total annual resources available
for AIDS, 1996–2005
9 000
8 000
7 000
6 000
5 000
PEPFAR
( US$ millions )
4 000
3 000
Global Fund
World Bank MAP Launch
2 000
Signing of Declaration of
Commitment on HIV/AIDS
1 000
1996
1997
1998
Source: Lancet, 2006; 368: 526–30
1999
2000
2001
2002
2003
2004
2005
Prices of ARV therapy
Comparison of outcome in patients on ART in
high- and low-income settings
 18 programmes in Africa, Asia, South
America (4,810 pts), 12 cohorts from Europe
and North America (22,217 pts)
 Low-income patients:
- More females (51% vs 25%)
- Lower CD4+ (108 vs 234 per cu mm)
- More NNRTI (70% vs 23%)
Source: ART-Link and ART-CC Groups; Lancet, 2006
Comparison of mortality in the months after
starting ART in low- and high-income
settings
16
(Log scale of mortality rate %)
Adjusted hazard ratios
8
4
2
1
0.5
1
2
3
4
5
6
7
(Months from starting HAART)
Source: ART-Link and ART-CC Groups; Lancet, 2006
8
9
10
11
12
WHO: public health approach to initiating ART
WHO CLINICAL
STAGING
CD4 TESTING NOT
AVAILABLE
1
CD4 TESTING AVAILABLE
Do not treat
Treat if CD4 count is below 200
cells/mm3
3
Treat
Consider treatment if CD4 count
is below 350 cells/mm3 and
initiate ART before CD4 count
drops below 200 cells/mm3
4
Treat
Treat irrespective of CD4 cell
count
2
Source: WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in resource-limited
settings: towards universal access
Recommendations for a public health approach, 2006 revision
Mortality in patients on ART in low-income
settings
 73% deaths occurred in persons starting
therapy at CD4+ <100 per cu mm
 38% deaths occurred in first month, 80% in first
4 months
Source: ART-LINC and ART-CC Groups, Lancet, 2006
User fees and treatment outcome
1. Meta-analysis of 10 studies by Ivers LC et al.:


Free laboratory testing did not affect outcome
Free treatment was associated with 29-31%
increase in viral load suppression
Source: Ivers LC et al., CID, 2005
2. ART-LINC:

75% lower mortality at 1 year with free treatment
Source: ART-LINC, Lancet, 2006
Countries implementing WHO HIV ResNet
Drug Resistance protocols
Resistance map
Tuberculosis in patients on ART
1. Incidence


Six countries: 3.0 – 17.6 per 100 py
South Africa: 3.4 per 100 py (CD4+ <200)
1.7 per 100 py (CD4+ 200-350)
2. Recurrence

Côte d’Ivoire: 11.0 per 100 py
Sources: Badri et al., Lancet, 2002; Seyler et al., Am J Respir Crit Care Med, 2005; Bonnet et al., AIDS, 2006
Priorities to reduce mortality of HIV/AIDS
patients in low-income settings
 Expand HIV testing for earlier diagnosis
 Ensure essential package of care for HIV-infected
patients, including TB screening and co-trimoxazole
 Provide ART for Stages 3 and 4 disease as early as
possible
 Expand CD4+ testing for earlier initiation of ART
 Abolish user fees
Universal Access
2005 G8 Summit at Gleneagles, Final Communiqué:
“…working with WHO, UNAIDS and other international
bodies to develop and implement a package of HIV
prevention, treatment and care, with the aim of as
close as possible to universal access to treatment for
all those who need it by 2010.”
The health sector's contribution to achieving
Universal Access
Expanding testing and counseling
Maximising
prevention
Accelerating
treatment scale up
Strengthening health systems
S
T
R
A
T
E
G
I
C
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N
F
OR
M
A
T
I
ON
AIDS cases, deaths and persons living with
AIDS in the United States, 1985-2003 (CDC)
(AIDS cases and deaths in thousands)
80
70
450
400
AIDS Cases
350
60
300
50
250
40
Deaths
200
30
150
20
100
10
50
0
1985
1987
1989
1991
1993
1995
Years
1997
1999
2001
0
2003
(Persons living with AIDS in thousands)
Persons living with AIDS
90
Health systems strengthening
WHO framework for monitoring the health
sector: components of access
Availability:
reachable and
affordable services that meet
a minimum
standard
Health
interventions
Coverage:
people using
the intervention
among those
who need it
Impact:
reduction in new
infection rates
and improved
survival of
those infected
Testing and Counseling
Uganda
Lesotho
Kenya
Family VCT
Universal TC
Provider-initiated
TC
Routine HIV testing in Botswana
 Routine testing in health care settings with right to
decline was introduced in 2004
 1 268 adults were interviewed
 81-93% were in favour, said testing would be facilitated,
treatment access enhanced
 98% of persons tested expressed no regret
 Principal reasons for not testing:
- fear (49%)
- "no reason to believe infected" (43%)
Source: Weiser SD et al, PLOS Medicine, 2006
Working towards universal access by 2010
Towards Universal Access
Towards Universal Access