hiv in the world 2009 · priorities hiv treatment resource-poor settings safer and more robust...
TRANSCRIPT
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HIV in the world2009
Joep M.A. Lange
Center for Poverty-related Communicable Diseases
Academic Medical Center / University of Amsterdam
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The “failure” of HIV prevention
– Despite positive trends, the number of new infections
outpaces the number of people being put on treatment
(5 : 2)
– Concentrated epidemics with high incidence rates in
particular populations
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Why this “failure” of HIV prevention?
– Lack of access to prevention tools (education,
condoms, clean needles, etc.)
– In many contexts behavioral change not an easy
target
– Vulnerable position of women & other populations
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Vulnerable postion of women
� Leads to great need for female-controlled
prevention technologies
� Female condoms provide alternative to male
condom, but ultimately still possibility of male
control (apart from cost, etc.)
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Apart from increasing access to “classic” HIV prevention tools, what can be done?
– Circumcision yes
– Female condom yes
– Microbicides / diaphragm ?/??
– STD treatment (GUD, esp. HSV2) ???
– Vaccines ??????????????????????????????
– Oral prophylaxis (PREP) ?/(yes!)
– HAART for prevention ?/(yes!)
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A concise history of HIV and its treatment in the “developed” world
� 1981: “emergence” of AIDS epidemic in gay men East and West Coast US
� 1983/84: discovery of the causative agent: HIV
� 1987: first active antiretroviral on the market (ZDV)
� 1996: HAART
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Why has this been accomplished?
� The presence of substantial markets in the “developed”
world
� An unprecedented civil society movement and
community engagement
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Reasons not to introduce HAART in resource-poor settings in 1996
� Too expensive
� Too complex
� Prevention more important than treatment
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What has made the difference for the “developing” world?
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Money…
� Establishment of funding mechanisms:
– World Bank Multicountry AIDS Program (MAP, 2000)
– Global Fund to fight AIDS, TB and malaria (GFATM,
2002)
– President’s Emergency Plan for AIDS Relief (PEPFAR,
2003/2004)
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Leadership
� Community engagement (TASO, etc.)
� Political leadership
� Price reduction of antiretrovirals (Accelerating Access Initiative, etc)
(2000)
� Declaration of Commitment of the United Nations General
Asssembly Special Session on HIV/AIDS (UNGASS) (2001)
� WHO Treatment Guidelines + uptake of antiretrovirals in WHO Model
List of Essential Medicines (2002)
� Target setting: WHO’s “3by5” initiative
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However, despite impressive scale-up ,…
� Large number still untreated
– More new infections than people being put on treatment
� Reliance on cheap fixed dose NNRTI-based combinations for first line therapy
– Toxicity
– Durability
� High early mortality rates (because of late treatment start)
� Limited availability of second line options
� Limitid monitoring capacity (no pVL)
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Major challenges in the antiretroviral scale-up
� Weak health care infrastructure
� Low numbers of health care workers
� Unreliable supply lines
� Sustainability…?
� Impact of disease-specific programming on fragile health systems…?
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Impact of disease-specific (HIV) programming on fragile health systems?
• Lack of good data
• Counters braindrain
• Has upgraded facilities
• Has shown that complacency can be overcome
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The AIDS response did create islands of sufficiency in a swamp of insufficiency (Gorik Ooms, MSF)
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The way forward
We need to move from AIDS-exceptionalism
to health-exceptionalism
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Reality: double burden = double response
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Priorities HIV treatment resource-poor settings
� Safer and more robust first line regimens:
– will not only prevent human suffering, but as well save money in the end
– these should be studied in African settings; subtypes may matter!
� Earlier treatment initiation
– requires massive scale up of (VC)T
� Cheap and simple CD4 and pVL tests
� Health systems strengthening (incl. financing)
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Mortality over four years
Sub-Saharan Africa
Europe & North America
Months after start of ART
0 12 24 36 48
Cum
ula
tive m
ort
alit
y (
%)
0
5
10
15
CROI 2007 – mortality - 31
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Sub-Saharan Africa
Year
1994 1996 1998 2000 2002 2004 2006
CD
4 c
ell
co
un
ta
t sta
rt o
f A
RT
0
50
100
150
200
250
300
350
Europe & North America
MSM
HET
IDU
CROI 2007 – CD4 at start – 11
Median CD4 counts at start of ART Trends over time
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SAPIT Study (South Africa) 1
� Starting Antiretroviral therapy at three Points in Tuberculosis therapy (N = 645)
– Early integrated treatment: ART as soon as possible after TB treatment (within two months)
– Later integrated treatment: ART started after the two-month intensive phase of TB treatment is completed (generally month three or four)
– Sequential treatment
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SAPIT Study 2
� Safety Monitoring Committee decided to terminate the sequential treatment arm:
– 55% lower death rate in the two integrated treatment arms
– Reduction in mortality significant in both patients with CD4+ cell counts < 200/mm3 and those with counts 200 –500/mm3
� The two integrated arms will continue until 2010 to determine whether there is any difference between those
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Parachute Use to Prevent Death and Major
Trauma Related to Gravitational Challenge: Systematic Review of Randomized Controlled
Trials
Gordon C S Smith, Jill P PellBMJ VOLUME 327 20–27 DECEMBER 2003
AbstractConclusions: We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double blind, randomised, placebo-controlled, crossover trial of the parachute. Parachutes’ effectiveness has
not been proven with randomised controlled trials.