From "3 by 5" to Universal From "3 by 5" to Universal AccessAccessKevin M. De CockKevin M. De Cock

Director, HIV/AIDS DepartmentDirector, HIV/AIDS Department

10 Years of HAART10 Years of HAART

25 Years of AIDS25 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.

From "3 by 5" to Universal Access: From "3 by 5" to Universal Access: outlineoutline

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- Antiretroviral therapy coverage in low- and middle-income countries, June and middle-income countries, June 20062006Geographical region Number of people

receiving ARV therapy

Estimated need

Coverage

Sub-Saharan Africa 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%

Europe and Central Asia 24 000 190 000 13%

North Africa and the Middle East

4 000 75 000 5%

Total 1 650 000 6 800 000 24%

20 low- and middle-income countries in sub-Saharan 20 low- and middle-income countries in sub-Saharan Africa, Asia, Latin America and the Caribbean treated Africa, Asia, Latin America and the Caribbean treated more than 50% of those in need, June 2006more than 50% of those in need, June 2006

ARV Therapy: global need, June ARV Therapy: global need, June 20062006

1

5

4

Sub-Saharan Africa

Latin America and the Caribbean

East, South and South-East Asia

Europe and Central Asia

North Africa andthe Middle East

3

2

(Nu

mber

of

people

in

mill

ions)

Unmet need

Receiving ARV therapy

70% of the total unmet need70% of the total unmet need

Women's access to HIV treatment, Women's access to HIV treatment, June 2006June 2006

United Republic of Tanzania

Mozambique

Malawi

Zimbabwe

Zambia

Central African Republic Botswan

a Kenya

Côte d'IvoireNamibia

Rwanda

BurundiSouth Africa

Uganda

Nigeria

10% 40% 50% 60% 70%20% 30%

Percentage of adults on ART who are women Percentage of HIV-infected persons who are women

Children's access to HIV treatment, Children's access to HIV treatment, June 2006June 2006

Median: 8%

Latin America

Median: 8%

Africa

Median: 5 %

Asia

Access to PMTCT services in sub-Access to PMTCT services in sub-Saharan Africa, 2005 Saharan Africa, 2005

Guinea Bissau

Zimbabwe

Zambia

Central African Republic

Kenya

Côte d'Ivoire

Rwanda

SwazilandBurundi

Benin

Togo8080

Namibia7070

6060

5050

4040

3030

2020

1010

Uganda

Gabon

LesothoMozambique

Percentage of HIV-infected pregnant women receiving ARV prophylaxis for PMTCT

(Perc

enta

ge

covera

ge)

Treatment access among IDU in Eastern Europe

Serbia and

Montenegro

Czech Republic

Moldova Estonia Ukraine

100

90

80

70

60

50

40

30

20

10

Lithuania Croatia

RussianFederation

IDU as % of people living with HIV

IDU as % of people on ART

Equity of treatment access Equity of treatment access – knowledge gaps– knowledge gaps

Coverage and quality of care in:

Time Place Person

Estimated total annual resources Estimated total annual resources available for AIDS, 1996–2005available for AIDS, 1996–2005

PEPFAR

Source: Lancet, 2006; 368: 526–30

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

9 000

8 000

7 000

6 000

5 000

4 000

3 000

2 000

1 000

World Bank MAP Launch Signing of Declaration of

Commitment on HIV/AIDS

Global Fund

( U

S$ m

illio

ns

)

Prices of ARV therapyPrices of ARV therapy

Comparison of outcome in patients on Comparison of outcome in patients on ART in high- and low-income settingsART 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 Comparison of mortality in the months after starting ART in low- and months after starting ART in low- and high-income settingshigh-income settings

Source: ART-Link and ART-CC Groups; Lancet, 2006

16

8

4

2

1

1

2 3 4 5 6 7 8 9 10 11 12

0.5

(Log s

cale

of

mort

alit

y r

ate

%

)

(Months from starting HAART)

Adjusted hazard ratios

Source: Source: WHO guidelines on WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal accessresource-limited settings: towards universal accessRecommendations for a public health approachRecommendations for a public health approach, 2006 revision, 2006 revision

WHO CLINICAL STAGING

CD4 TESTING NOT AVAILABLE

CD4 TESTING AVAILABLE

1Do not treat Treat if CD4 count is below

200 cells/mm32

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

WHO: public health approach to initiating ARTWHO: public health approach to initiating ART

Mortality in patients on ART in low-Mortality in patients on ART in low-income settingsincome 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 outcomeUser 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 suppressionSource: 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 Countries implementing WHO HIV ResNet Drug Resistance protocolsResNet Drug Resistance protocols

Resistance map

Tuberculosis in patients on ARTTuberculosis 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 Priorities to reduce mortality of HIV/AIDS patients in low-income HIV/AIDS patients in low-income settingssettings 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 AccessUniversal 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.”

Expanding testing and counselingExpanding testing and counselingExpanding testing and counselingExpanding testing and counseling

Accelerating Accelerating treatment scale uptreatment scale up

Accelerating Accelerating treatment scale uptreatment scale up

Maximising Maximising preventionprevention

Maximising Maximising preventionprevention

Strengthening health systems Strengthening health systems Strengthening health systems Strengthening health systems

SSTTRRAATTEEGGIICC

IINNFF

ORORMMAATTII

ONON

SSTTRRAATTEEGGIICC

IINNFF

ORORMMAATTII

ONON

The health sector's contribution to achieving Universal Access

AIDS cases, deaths and persons living AIDS cases, deaths and persons living with AIDS in the with AIDS in the United States, 1985-United States, 1985-2003 (CDC)2003 (CDC)

Deaths

Persons living with AIDS

AIDS Cases

0

10

20

30

40

50

60

70

80

90

1985 1987 1989 1991 1993 1995 1997 1999 2001 2003Years

(AID

S c

ase

s and d

eath

s in

thousa

nds)

0

50

100

150

200

250

300

350

400

450

(Pers

on

s liv

ing w

ith A

IDS

in

th

ou

sands)

Health systems strengtheningHealth systems strengthening

WHO framework for monitoring the WHO framework for monitoring the health sector: components of accesshealth sector: components of access

Health interventions

Availability:reachable and affordable ser-

vices that meet a minimum

standard

Coverage: people using

the intervention among those who need it

Impact:

reduction in new infection rates and improved

survival of those infected

Testing and CounselingTesting and Counseling

Family VCT

Uganda

Universal TC

Lesotho

Provider-initiated TC

Kenya

Routine HIV testing in BotswanaRoutine 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 Working towards universal access by 20102010

Towards Universal Access

Towards Universal Access