Fabio Mesquita, MD, PhDDirector of the Brazilian Ministry of Health’s HIV/AIDS and Viral Hepatitis Department

www.aids.gov.br

July 20th, 2014

Evidence and Policy Gaps on ART at 500 CD4, TasP and PrEP: Why are we not scaling up the use of ART more aggressively?

Clinical Protocol and Therapeutic Guidelines for Management of the HIV Infection in

Adults Launched on World AIDS Day

and published by Ordinance No.

27, on November 29, 2013

30 days’ public consultation

Published online as well as in

PDF format, allowing for simpler

and faster review of

recommendations.

Establishing lines of treatmentFirst-line:

Preferred regimen – TDF + 3TC + EFVAlternative NRTIs: Zidovudine, abacavir, didanosineAlternative NNRTIs: Nevirapine

Second-line:Preferred PIs: LPV/rAlternative PIs: Atazanavir, fosamprenavir (with ritonavir booster)

Third-line:Darunavir/r, Tipranavir/r, Raltegravir, Etravirine, Maraviroc, Enfuvirtide

Dispensing of alternative ARV drugs to new patients - rather than preferred regimen - only when justified by doctor.

Brazil incorporates TasP in its national recommendations

Treat every HIV positive regardless CD4

Reduced transmissibility: reduction in HIV

transmission in HAART early treatment

Clinical benefits by decreasing inflammatory

action and aging effects related to the HIV

infection

We don’t need any more scientific data: we

must prevent viral replication from occurring by

intervening

A continuous increase in people in ART

In 2014, the CD4 counts of 40% of the patients who began treatment was greater than 500

Distribution of individuals who began ART according to CD4 counts carried out 6 months earlier at most, by year of beginning in Brazil, 2009-2014*

(*) Up to June 2014.

Our goal for 2014: at least 100 thousand more people in treatment

New PLWHA on ART in the first semester of each year. Brazil, 2012-14

2014: a 30% increase, approximately, when compared to the same period in 2013

PrEP

We need more information to implement this as a public

policy – to assess the possible impacts of its use in real

life, outside of the controlled environment of a clinical trial

– adhesion, use of other prevention methods, disinhibition

etc.

In Brazil:

Studies for its implementation in health services are in

progress

Sustainability of the universal access policy in Brazil

Price negotiation;

National production: 13 of the 37 types of antiretroviral drugs

available in the Brazilian public health system are nationally

produced;

Rational use of ARVs: only 5% of the patients in third-line ART

– third-line drugs alone are responsible for 35% of the total cost

of ARVs.

Presently: 350 thousand people in ART – 75% present

undetectable VLs

Challenges to expanding treatment

Treatment simplification: use of combined fixed doses and regimens with greater

dosing convenience;

Rational use of antiretroviral drugs: sequential use of ARVs to sustain treatment

success for as long as possible;

Priority to begin treatment given to patients according to clinical and immunological

criteria X early treatment for everyone, without distinction;

A new model of attention to HIV – increased access to and quality of treatment

resulting from the involvement of primary care in ARV management;

Global challenges for funding the HIV response in next few years, taking into account

that communicable diseases are now less of a priority in the international agenda;

ARV costs in a scenario in which there is a continuous increase of new patients in

treatment.