an update on hiv prevention and treatment prof francois venter wits reproductive health and hiv...
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Tensions… Prevention versus HIV treatment HIV versus other illnesses Public health versus human rights versus the law Government versus donor responsibilityTRANSCRIPT
An update on HIV prevention and treatment
Prof Francois VenterWits Reproductive Health and HIV Institute (WRHI)
University of the WitwatersrandOct 2012
AIDS in Africa
Tensions…
• Prevention versus HIV treatment• HIV versus other illnesses• Public health versus human rights versus
the law• Government versus donor responsibility
Who is at fault?
• Politicians and voters• Public Health experts • Clinicians• Researchers• Donors
Kenya, 245,162
16%Mozambique,
156,10810%
Tanzania, 139,151
9%
Uganda, 78,769, 5%
Eritrea4,838 Madagascar
1,491Mauritius
584Comoros
28
South Africa, 473,499
31%
Zambia, 103,077
7%
Ethiopia, 94,489
6%
Malawi, 86,905, 6%
Rwanda, 9,225, 1%
Botswana, 13,518, 1%
Swaziland, 15,131, 1%
Namibia, 16,082, 1%
Angola, 21,777, 1%
Lesotho, 22,666, 1%
Zimbabwe, 45,652, 3%
Eastern & Southern Africa
1.5 million (57%
Rest of the world1.2 million (43%)
Global new infections, 2.7 million ESA new infections,
Prov. estimate 1.5m
Estimates of New Infections in Eastern and Southern Africa, 2007
0
150
300
450
600
2000 2005 2010 2015
South AfricaBrazilNamibiaChile
Measurement of Generally Accepted Indicators Reveals that the South African Healthcare System is Functioning Poorly by International Standards
16
13
31
260
300
250
230
540
6
8
16
110
210
230
300
400
450
1,9001,800Afghanistan
India
South Africa
Iraq
China
Namibia
Brazil
Chile
United Kingdom
Netherlands20002005
Note: MMR = Number of Maternal deaths per 100,000 *Public Sector deliveries estimated. Live births is used as a proxy for the number of pregnancies annually.MMR is an indicator of the quality of a health care system Source: WHO Maternal Mortality Report, 2007, StatsSA
Maternal Mortality Rates by Geography (2000 vs 2005)
MDG 2015 Target
Trend Projection for Maternal Mortality Rate until 2015
58
2
Since the SA ARV rollout started…
• 2 million people on treatment (& million worldwide)
• 5 million deaths• 5 million new infections
Implications
• HCT campaign 1st April 2010….• 15 million tests, linked to TB, other chronic
illness screening
New guidelines
CD4
Gets HIV!
Needs ARV’s
8 to 10 years
What happens if you get HIV?
Wellness – nutrition, exercise, stop smoking, safe sex, mental health, ↓ alcohol
How good are the antiretrovirals?
Before and after initiation of ARV therapy!
Thapelo
Before and after initiation of ARV therapy!Before and after initiation of ARV therapy!
ART outcomes - good news• National programmes
reporting good outcomes
• 1 year survival estimated as 93-95%
• 2 year survival 91%
• SA life expectancy up
How long will people live for?• ? 20 years or more on the
treatment package !! – CROI 2005
• Danish study – 39 years!• American – lose 12 years• French – NORMAL after
6 years• Uganda – normal!• Geriatrics, fertility
In summary, what has changed:• CD4 350, for all• Initiation of infants immediately• New maternal health/ PMTCT• New 1st line drugs for adults, kids• Altered second line• Expedited referral with timelines• Decreased monitoring• TB• Nurse initiation focus
Therapy for Early HIV Infection
200
500< 200
350CD4 Count (cell/mm3)
Symptomatic
(Stages 3 & 4)Asymptomatic
(Stages 1 & 2)
Clinical Symptoms
164187
102
181
200192
87 239
163
97
134
179
97100125
12386
122103 53
157 20695
72
Review of data from 2003-2005 from 176 sites in 42 countries (N = 33,008)
When Is Antiretroviral Therapy Started?
Egger M, et al. CROI 2007. Abstract 62.
Children
• All children less than 1 year of age
• Children 1 – 5 years with clinical stage 3 or 4 or CD4 ≤ 25 % or absolute CD4 count < 750 cells/µl
• Children ≥ 6 years to 15yrs with clinical stage
3 or 4 or CD4 < 350 cells/µl. Huge implications for PCR screening!
MDR and XDR?
Treatment as prevention
• Prevention programmes results very disappointing
• Can reducing the viral load earlier have a public health impact?
• Convenient convergence!
• Essentially, treatment IS prevention
1st line adults
• All new patients needing treatment, including pregnant women
- TDF + 3TC/FTC +EFV/NVP • Contraindication to TDF: renal disease
AZT+ 3TC +EFV/NVP• For those on existing d4T, remain, but
vigilance urged
ddI
d4T
AZT
3TC
2 Nukes Non-nuke
Efavirenz/ nevirapine
Protease
Kaletra
Failure – VL>5000Toxic!
Who is still taking d4T?
28.4
78.6
47.6
77.8
45.8
62.7
7.3
24.0
4.7
8.98.6
25.9
5.26.1
11.2
3.5
11.10
6.01.8 1.3
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Cote d'Ivoire Mozambique South Africa Tanzania Zambia
d4T-3TC-NVP d4T-3TC-EFV d4T-FTC-EFVd4T-FTC-NVPAZT-3TC-NVPAZT-3TC-EFVTDF-FTC-EFVTDF-FTC-NVPd4T-3TC-LPV/rOther
1.30.14.6
0.0020.1 0.22.1
9.1
4.6
0.1
Marlink R et al , IAC 2008 (WEAXO106)
Westreich DJ, et al, Tuberculosis treatment and risk of stavudine substitution in first-line antiretroviral therapy, Clin Infect Dis. 2009 Jun 1;48(11):1617-23
Side effects potentiated by TB Rx
Major issue: PMTCT
• Complex regimens – being updated
What can stop us?
• Human resources• Budget and treasury• Beaurocracy and legislation
Context of care
Challenges
The difference?What we want• INH• CTX• Regular monitoring• Pap smears, fertility
planning • ‘Wellness’ – ‘prevention
for positives’• (no weekend work,
patient in clinic when suits us, keep their appointments)
What patients want• Being valued• No queues• Same health care worker• Tablets that work• Confidentiality• Files and blood tests that
don’t go missing• Information that is
appropriate• Grants!• Appointments, hours that
don’t impact on work
• The biggest challenge to our programmes is NOT safe or effective drugs or HIV testing – it is retention in care after HIV diagnosis
1st prize is a bulletproof 1st line ARV regimen
• Tolerability > forgiveness (NNRTI vs PI)• BUT – presupposes good support and
adherence• 2-3% migration to 2nd line – accumulating
body of patients• Long haul – probably 50% of patients
need minimal support
FDCs
• More for pharmacists than patients!• Packaging and colours would be great
Issues around paediatrics
• The least “system proofed” group• Try to harmonise with adults• Weight of liquid formulations – score
tablets, pay attention to ‘crushability’
OI drug needs
• Amphotericin B• Macrolides - MAC• Gancyclovir – CMV, possibly for other
illnesses• MDR treatment • (Rifabutin)
PoC technologies?
• Proliferation of technologies with parallel lab system - ?justified in an HIV silo ?toxicity monitoring required
• Gene Xpert• Viral load• ?CD, ?Resistance• ?POC rapid HIV test re-evaluation• Sober reflection on the tech requirements
Summary of big ‘short term’ treatment and systems gaps?
• Earlier diagnosis and retention • Bigger emphasis on more sophisticated adherence,
esp toxicity management – preserve 1st line• Better packaging of drugs, FDCs• New drugs for toxicity • OI drugs• Better and faster diagnosis of TB, VL; Reassess rapid
HIV• Simpler guidelines, align paeds and adult guidelines• Expansion of who gives ART
HIV has showed what we can do
• Opportunity to fix the whole health care system now
• Heed our marching orders for 2012!
The End