effective, convenient, and relatively nontoxic. ART regimens should be chosen in consideration of a patient’s particular clinical situation. Successful treatment is associated with durable suppression of HIV viremia over years, and consequently, ART reduces the risk
Virginia Hughes: Outlook for a Cure. Nature 15 July 2010
Massive increase in AIDS funding, especially after the UNGASS declaration in 2002, followed by the global fund and later by PEPFAR.
And treatment benefit became clear, the AIDS-related mortality began to decline in sub-Saharan Africa and the Caribbean in 2005. Different patterns have emerged in other regions. In North America and Western and Central Europe, deaths due to AIDS began to decline soon aſter antiretroviral therapy was introduced in 1996. And it is estimated that since 1996 the availability of ART has saved close to three million lives.
A community based program in South Africa shows the same effect
Opnieuw, gebrek aan virale lading mag geen obstakel vormen. Op basis van klinische en immunologische criteria kan je ook therapie falen vermoeden, … . vinden experts. Maar waar is de evidence?
Verschillende studies hebben aangetoond dat inderdaad de diagnostische accuraatheid van de WGO crioteria laag is. Niet alleen worden slecht 24-33% van de patiënten geïdentificeerd, maar bovendien is de PPV erg laag, wat leidt tot onnodig switchen naar een tweede lijnsbehandeling
Two OPD in Durban, PITC
Er zitten oon cohortes in met betalende patiëte
Parents and a younger daughter in Uganda have H.I.V. but only the daughter is eligible for drugs.
http://www.msf.org.uk/UploadedFiles/HIV_report_No_Time_To_Quit_May_2010_201005273105.pdf While the exceptional drive and resource mobilisation since 2001 allowed us to fight effectively against the HIV/AIDS epidemic over the past years, a sense of denial has set in among the donor community about this ongoing crisis. For the past year and a half, donors have increasingly voiced concern regarding the cost, sustainability and relative priority of HIV/ AIDS, against the background of an ostensible lack of funds.Access is about sufficient available treatment slots and ART sites distributed across the country. Today already, poorer patients cannot access the ARV lifeline, and rural areas in particular are underserved.In October 2010, a donor replenishment conference is planned to mobilize funds for the period 2011−2013. Donors have already requested the Global Fund to lower its financial ambitions. In 2009, the initial estimated needs were set at USD 20 billion for 2011-2013. In 2010, this estimate was revised down in the form of two additional scenarios, USD 13 or 17 billion respectively. All three scenarios inadequately reflect demand, as none include the additional resources required to implement the new WHO guidelines on earlier treatment and improved drug regimens. These funding levels will force rationing of treatment under Global Fund grants and accepting to support sub-standard treatment. In the Democratic Republic of Congo (DRC) 283,055 people are estimated to be in need of ART (as per the old WHO initiation criteria), but by the end of 2009, only 34,967 were reportedly on treatment - roughly 12% of the need. 44On top of the existing backlog of patients waiting for care, an estimated 179,000 more people will be become eligible for ART every year (as per old WHO criteria). In 2009, the Global Fund was supporting 1,000 new initiations per month. Now the revised availability of funds for initiation has been cut six-fold to 2,000 per year . The consequence is that in DRC – in spite of the acute crisis situation - dramatically fewer patients can start ARV. However, there is not yet unified donor support for earlier treatment with an improved first-line treatment regimen. For example, PEPFAR’s director has voiced reluctance towards implementing the new WHO treatment guidelines for earlier treatment. 52 This reluctance is translating into support of a lower standard of care in recipient countries. Most governments in the region simply cannot implement such a change without donor support
Padma TV, New Dehli: Despite lofty promises, many donor agencieshave not delivered. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria pledged US$10 billion a year when it was set up in 2001, but has delivered only US$3 billion a year so far. National governments are no better at fund- ing their AIDS programmes. At an April 2001 summit in Abuja, Nigeria, 52 African coun- tries pledged to allocate at least 15% of their national budgets for health. In 2007, only three (Botswana, Djibouti and Rwanda) were on track, and three others (Burkina Faso, Liberia and Malawi) had reached some targets. These slow and bureaucratic governmen These days, 92% of those receiving treatment in low- and middle-income countries take generic drugs made in India — the ‘pharmacy of the developing world’
ARV = drugs, ART = therapy = broader DPS (not MISAU, as requested by DPS)
ART = therapy, ARV = drugs 24% : report of MOH, end 2009 for central MBQ, more recent then national 31% of 2008
Dec2010 1final ll
Successes and Challenges of Roll-out of ART in Low-Income countries Lut Lynen Institute of Tropical Medicine, Antwerp
Total available resources for AIDS 1986-2008 13 billion 2008 [i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006); [ii] 1986-1993 data: Mann.&. Tarantola, 1996 Notes :  1986-2000 figures are for international funds only;  Domestic funds are included from 2001 onwards 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 US$ million 292 1623 8.3 billion Signing of Declaration of Commitment on HIV/AIDS,UNGASS 1995 2000 2005 1987 1990 Less than US$ 1 million 59 212 World Bank MAP launch Global Fund PEPFAR 257 UNAIDS Gates Foundation 10 000 8.9 billion 10 billion 7.1 Source : UNAIDS & WHO unpublished estimates, 2007
Price reduction through generic competition 3TC-D4T-NVP
ART scale up in the Developing World <ul><li>Access and implementation has been greatly influenced by WHO guidelines </li></ul><ul><ul><li>2002 </li></ul></ul><ul><ul><li>2003 </li></ul></ul><ul><ul><li>2006 </li></ul></ul><ul><ul><li>2010 </li></ul></ul>
Late initiation of treatment in Sub-Saharan Africa leads to high initial mortality ART-LINC
Confronting reality <ul><li>Review of data from 2003-2005 from 42 countries, 176 sites, n=33,008 </li></ul>Egger M, 14 th CROI, Los Angeles 2007, #62. Late!
Early Mortality- The Case For early HIV Diagnosis and Care (community based ART program SA) SOURCE: S Lawn et al: AIDS; 22 : 1897–1908 (2008)
Pediatric diagnosis and treatment 15% of HIV-exposed infants receive an HIV test within the two first months of life 28 % 28% of eligible children on ART
Use of simple 1 st and 2 nd line regimens AZT + 3TC + LPV/r TDF + 3TC or FTC + LPV/r TDF + 3TC or FTC + NVP AZT + 3TC + ATV/r TDF + 3TC or FTC + EFV AZT + 3TC + NVP TDF + 3TC or FTC + ATV/r AZT + 3TC + EFV Preferred 2 nd Line Options Preferred 1 st Line Options
Projected need for second-line ARV <ul><ul><li>The number of people is forecast to grow at a compound rate of around 40% between 2006 and 2010 </li></ul></ul>WHO working group, HIV Department, May 2007
Very few patients are on second-line regimens in LMIC WHO 2010: Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector
How do we suspect/diagnose treatment failure? VL>10,000 FIRST VL SECOND CD4 THIRD symptoms LATE DETECTION OF TREATMENT FAILURE Time Amount of CD4 or Amount of Virus ARV success ARV not success - Virus - CD4
Not available EXPERT OPINION, not EVIDENCE-BASED
10 12 10 8 Report Setting WHO Criteria Sens % PPV % An et al. 2003 2006 2006 2006 30 20 24 27 21 17 17 33 Uganda Rwanda South Africa Meya et al. Van Griensven Mee, P. et al Cambodia
Using VL to better decide when to switch ART Two possible approaches… Targeted Viral Load Routine Viral Load To avoid unnecessary switching To detect early adherence problems
Coverage of TB services for PLWHIV, 2009, SSA 1000 new HIV cases ART eligible =44% Know HIV status =33% Screened for TB= 5% Incident TB in PLWHV=3% TB-ART=0.5% IPT=0.2% UNAIDS 2010, WHO Global TB report 2009 On ART = 16% 67% Does not know the HIV status
How many start ART? HIV Tested HIV-infected CD4/results Eligible for ART Start ART 2,775 1,467 605 368 154 (42%) Failure to obtain CD4 Failure to start ART when eligible Median time to ART initiation: 100 days Bassett et al. AIDS 2010 – slide from Walenski R
<ul><li>* Serious barriers </li></ul><ul><li>- Transports costs </li></ul><ul><li>- Time spent queing </li></ul><ul><li> for treatment </li></ul><ul><li>- Logistical challenges </li></ul><ul><li>* Less influencial factors </li></ul><ul><li>- Stigma around HIV/AIDS </li></ul><ul><li>- Side effects </li></ul>Patients’ perception
START ART EARLIER !! With better drugs… Viral load accessible Infant diagnosis Long term retention Community involvement Social support systems
Zambia, Fredrick Sinyinza START ART EARLIER !! The number of people estimated to be in need of antiretroviral therapy at the end of 2009 increased from 10.1 million to 14.6 million [13.5 million–15.8 million] WHO report 2010 Dear Lut, “ With the implementation of the new guidelines rolling out of ART is not without challenges. At one of the main sites, where I work, the number of pt starting HAART since we started using the new guidelines ( late sept this yr) has increased by 37% ( considering pts with WHO stage 1,2 and CD4 200-350)), as a result the clinic has become congested, the patients are complaining and the lab is complaining (too many specimens).”
Patients (%) stratified by CD4 count soon after diagnosis (Swiss Cohort) M. Battegay, M. Rickenbach et al. 200 350
DIRECÇÃO PROVINCIAL DE SAÚDE TETE MOÇAMBIQUE Community ART Groups TOM DECROO
13 % HIV (2007) 31 % ART coverage 20 % lost to follow up Tete
<ul><li>SELFMANAGEMENT </li></ul><ul><ul><ul><li>patients </li></ul></ul></ul><ul><ul><ul><li>as partner in care </li></ul></ul></ul><ul><ul><ul><li>distribute ARVs </li></ul></ul></ul><ul><ul><ul><li>in the community </li></ul></ul></ul>please find here latest link http://vimeo.com/12765892