TEST AND ...TO TREAT OR NOT TO TREAT? Roger TATOUD, Ph.DInternational HIV Clinical Trials Research Management Office Imperial College London Vienna, 17thJuly 2010 MSM Global Forum
DOES IT WORK? CAN IT WORK? Relevance of mathematical modelling Velasco-Hernandez JX, et al. Could widespread use of combination antiretroviral therapy eradicate HIV epidemics?. Lancet Infect Dis 2002; 2: 487-493. Granich RM, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009 Jan 3;373(9657):48-57. Epub 2008 Nov 27. testing all adolescents and adults at least 15 years old once a year... 90% programme coverage by 2016 with immediate start (2010) The funding needed to implement the theoretical strategy for an epidemic of South African-type severity peaks in 2015 at $3·4 billion per year (range $2·2 billion—$5·3 billion) Echoing the Swiss Statement “An HIV-infected person on antiretroviral therapy with completely suppressed viraemia “effective ART”) is not sexually infectious, i.e. cannot transmit HIV through sexual contact.” This statement is valid as long as: the person adheres to antiretroviral therapy, the effects of which must be evaluated regularly by the treating physician, and the viral load has been suppressed (< 40 copies/ml) for at least six months, and there are no other sexually transmitted infections. Prevention of Mother to child Transmission In 2008, 45% [37%-57%] of HIV-positive pregnant women in low- and middle-income countries received ARV, up from 35% in 2007 and 10% in 2004.
COST EFFECTIVE? Cost-effectiveness estimates in low- and middle-income countries Bongaarts J Science. 2010 Jun 11;328(5984):1359-60. “People are struggling to find resources “Virtually every day, we have to turn to honor the commitments we have away patients who need treatment, made.” including breast-feeding women.” “We’re not at a cap point yet. If it gets “We have to tell them ‘There is a worse, we’ll have another discussion.’’ freeze.’” Ambassador Eric Goosby Dr Peter Mugyenyi US global AIDS coordinator Joint Clinical Research Center. Kampala, Uganda Boston Globe April 11, 2010
HUMAN RESOURCES AND EFFICIENCY Healthcare Worker Country Number/1000 Malawi 0.02 PHYSICIAN Uganda 0.12 UK 2.14 Malawi 0.28 NURSE Uganda 1.31 UK 5.8 Malawi 0.03 LABORATORY Uganda 0.06 PERSONNEL UK 0.34Source : AVERTNurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): arandomised non-inferiority trial.Sanne I. et al, The Lancet Jul 03, 2010, Volume 376HIV-positive individuals with a CD4 cell count of less than 350 cells per μL or WHO stage 3 or 4 disease wererandomly assigned to nurse-monitored or doctor-monitored ART care.408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; allparticipants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in thenurse group and 179 (44%) in the doctor group.
IMPLEMENTABLE ? Developing World Developed World Style over stigma: The designer sexual health clinic that could be mistaken for a boutique hotel. (Daily Mail Reporter 12/05/09)Functionality over Style:Providing the minimum to ensurediagnosis, treatment and care.
STIGMA, DISCRIMINATION, OSTRACISM Wat Phra Baht Nam Phu, Lop Bury, Thailand Pasargadae Palace, Iran - Cyrus the great last resting place No Testing = No Treating Likoma Island, Lake Malawi
IS IT ETHICAL? Universal Testing or Coerced Testing? Treating people who do not feel unhealthy Evidences from Clinical Trial (START Trial – HPTN 052) Putting the onus on the HIV positive“we have to be careful that "treatment as prevention" doesnt slide into "forced treatment as prevention." Indeed, both of these strategies expose the blunt self- interest of the HIV negative. Maybe if we cared about both HIV-negative and HIV-positive people equally, our strategies might better reflect a mutual respect?
100 M HURDLES Infrastructure Personnel Test Treat Follow up Adherence Resistance 2nd Line
TEST AND TREAT... AND OTHER NPTs Let’s not forget what worked and works.