maximizing the prevention benefit of art in asia

Maximizing the Prevention Benefit of ART in Asia

Ying-Ru Lo, MD, DTM&HWorld Health Organization

Regional Office for the Western Pacific, Manila, Philippines

Track C WESY02 Treatment as Prevention in Asia

International AIDS Society Conference, 3 July 2013 Kuala Lumpur, Malaysia

2 |

World Health Organization

Western Pacific Region

ContentContent

Epidemiology and new evidence

Programmatic challenges

Conclusions

3 |



Estimated no. of PLHIV by region, 2011Estimated no. of PLHIV by region, 2011

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

Sub-Saharan

Africa

East South and

South-East Asia

Latin America

& Caribean

Europe and

Central Asia

Middle East and

North Africa

Oceania

Est

ima

ted

no

. o

f P

LH

IV

Source: GARP 2012

Asia bears the 2nd highest burden of HIV (4.9 million of

global total of 34 million)

4 |



ART coverage in selected countries in Asia, 2011

ART coverage in selected countries in Asia, 2011

Source: GARP 2012

All ages

Country

% A

RT

cov

era

ge

Bangla

desh

Cambodia

China

India

Indones

ia

Lao P

DR

Mal

aysi

a

Mongolia

Mya

nmar

Nepal

Papua

New G

uinea

Philippin

es

Sri Lan

ka

Thaila

nd

Viet N

am

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

31%

95%

38%43%

24%

53%

37%

27%32%

24%

68%

51%

21%

71%

58%

Only 1 country reached > 80% coverage

By the end of 2012 number of people receiving ART • Globally, 9.6 million (64% of global target)• In Asia, 1.3 million

5 |



Evidence from HPTN 052Evidence from HPTN 052

HPTN 052 confirms that earlier ART reduces HIV transmission by 96% among discordant couples in stable relationship (Cohen et al, NEJM 2011)

Health Affairs 2012

6 |



China 10-fold increase in ART could decrease the number of HIV-

related deaths by 58% and the number of new infections by one-quarter by 2015 (Zhang et al, Sexual Health 2011)

Thailand > 60 % reduction of new HIV cases with increased uptake of

HIV testing among key populations and immediate treatment of all HIV-infected people (Peerapatanapokin et al. personal communication)

Vietnam Annual HTC and immediate treatment for key populations,

combined with scale-up of methadone maintenance therapy and condom use, will reduce new infections by 81% compared to current interventions (Kato et al, JAIDS 2013)

Modelling suggests that HIV testing and ART can avert new HIV infections in AsiaModelling suggests that HIV testing and ART can avert new HIV infections in Asia

7 |



A combination of interventions has greater impact than an intervention

delivered alone

A combination of interventions has greater impact than an intervention

delivered alone

8 |



Uptake along the cascade from HIV testing to treatment

Communication across the cascade with improved monitoring and evaluation

Dealing with acute and early HIV infection

Prevention and surveillance of HIV drug resistance

Effect of ART at population level depends on ……..

Effect of ART at population level depends on ……..

9 |



Metrics to monitor efficiency of the treatment cascade

Metrics to monitor efficiency of the treatment cascade

People with HIV do not know their statusLoss of individuals from HIV testing to care and ART

Vietnam 2011

% o

f pe

ople

livi

ng w

ith H

IV

% o

f pe

ople

livi

ng w

ith H

IV

China 2011

Source: UNAIDS 2012, NCAIDS 2011Source: UNAIDS 2012, VAAC 2011

10 |



Treatment cascade, Cambodia 2012Treatment cascade, Cambodia 2012

Estimated # PLHIV 74,572* (100%)

# on ART 48,913 (66%) # in HIV care 6587 (9%)

• Increasing # of individuals who know their HIV status

• Invest in monitoring

# HIV tested ? ? ?

* 2011 Estimates

Source: NCHADS 2012

11 |



Treatment cascade, Thailand, 2008-2011Treatment cascade, Thailand, 2008-2011

0

50,000

100,000

150,000

200,000

250,0002008 2009 20102011

Source: Adapted from Bhakeecheep (Personal Communication), National Health Security Office Thailand 2012

71% viral load suppression with

> 6 months on ART

No

. o

f p

eop

le

??

12 |



Communicating across the treatment cascade

Communicating across the treatment cascade

To achieve full impact of treatment, communication across services is critical

The cascade, although broken down by indicators, must be considered as a whole to estimate population-level impact

Requires coordinated programme approach

13 |



Note on need for unique identifier codesNote on need for unique identifier codes

As we move forward to develop and implement a national unique identifier code for use in the HIV testing, care and treatment cascade, we propose a running number plus additional identifying information, such as year, month, and province of birth, to identify persons as they make their way through the treatment cascade in confined clinical settings

Frits van Griensven, Cambodia mission, January 2013

14 |



Individuals with acute HIV infection have 8 to 26-fold higher risk for transmitting HIV vs. those with chronic HIV infection (Pilcher et al, Curr HIV/AIDS Rep 2006, Hollingsworth et al, J Infect Dis 2008, Cohen et al, NEJM 2011)

Relative contribution of early phase of HIV infection (3-6 months after infection) has been extensively modelled with differing results varying between 38% during first 4.8 months of HIV acquisition (Powers et al, Lancet 2011) and 2% during first month of HIV acquisition (Williams and Dye in Cohen et al, Plos Medicine 2012)

2012

15 |



Monitoring adverse events during earlier ART

Monitoring adverse events during earlier ART

HIV drug (antiretroviral) resistance impact of longer treatment required for earlier ART on

resistance is unknownmonitor early warning indicators

Adverse drug reactions

Risk behavior compensation (WEPDB0105, Doyle et al; MOLBPE30, Bavinton et al)

16 |



Low levels of transmitted HIV drug resistance in Asia, 2005-2010

Low levels of transmitted HIV drug resistance in Asia, 2005-2010

2005 2006 2007 2008 2009 2010 P-

value

South-East Asia

1.0 (0.6-4.0)

1.3 (0.1 - 3.5)

3.3 (2.8-18.9)

2.9 (0.6-8.2)

… 1.0 (0.0-5.8)

NS

Western Pacific

1.8 (0.2-4.5)

3.3 (1.0-6.6)

1.9 (0.6-3.7)

4.0 (1.6-8.2)

5.6 (3.2-8.7)

0.0 (0.0 -16.1)

NS

% of HIV drug resistance among ART –naive individuals from the published literature, by year and region (% with at least one drug resistance mutation), 2004–2010

NS: Not statistically significant. Source: WHO HIV Drug Resistance Report 2012.

17 |



As ART roll out continues, increased rates of HIVDR may occur

Routine, standardized, population-based surveillance of HIVDR is imperative and must be in place to detect potential future increase of HIVDR in a timely manner

HIV drug resistance surveillanceHIV drug resistance surveillance

18 |



Why ART as prevention implementation research in Asia?

Why ART as prevention implementation research in Asia?

Role of ART as prevention in concentrated HIV epidemics in Asia (SW, IDU, MSM) has not been addressed What needs to be done differently to

achieve the level of effectiveness observed in discordant couples in concentrated epidemics?

What is the cost of expanded HIV testing and earlier ART?

It is likely that earlier ART can be implemented as the pool of infected people to treat is small compared to generalized epidemics

Inter-country workshop on optimizing HIV treatment through the Treatment 2.0 Initiative, Yangon, Sept 13-14, 2012

Planned implementation research (January 2013)Planned implementation research (January 2013)Thailand Indonesia Cambodia Vietnam China

Population MSM MSMIDU++

All SD couples All SD couplesIDU++

All SD couplesMARPsTreat all

Goal To guide future national policy & strategy on earlier ART for MSM and/or FSW

To guide future national policy & strategy on earlier ART for SD couples, SWs, MSM and/ or IDU

Improve existing policy & strategy

Primary objective

Feasibility of repeat testing, immediate ART

New HTC approaches & uptake Adherence immediate ART

Feasibility of identifying partner (network approach), early ART, repeat testing

Feasibility improved implementation cascade

Programme strengthening

ART criteria Irrespective CD4TDF-based

Irrespective CD4TDF-based

Irrespective CD4 or CD4<500

Irrespective CD4TDF-based(possibly FDC)

Irrespective CD4TDF

Enrollment Outreach internetpeers

NGO and public services for MSM and IDU

HTC ART

HTCMethadone sitesPre ART

HTCART

20 |



HIV testing and counselling uptake is low among key populations

Substantial number of people diagnosed are not effectively linked to care

Attrition is high and adherence suboptimal

Monitoring and evaluation systems do not allow communication across the treatment cascade

HIV drug resistance surveillance is not sustained

ChallengesChallenges

21 |



Treatment as (for) PreventionTreatment as (for) PreventionGathering necessary information to inform

programmes and WHO guidelines

Serodiscordant couples &

programmatic update

Implementation & scale-up in

countries

Impact evaluation

Support countries on

implementation research

• WHO/NIH Cambodia, China, Indonesia, Thailand, Vietnam

• TREAT Asia/WHO Treatment as prevention of HIV workshop

• WHO China Treatment as Prevention workshop

• WPRO metrics workshop• Support to implementation research in countries• Piloting Unique Identifier Codes

2012 2013 2014

Metrics

How to improve efficiency of the HIV testing, care and treatment cascade?

2015

• WHO 2013 Guidelines: The use of ARVs for Treating and Preventing HIV

22 |



Sorakij Bhakeecheep, National Health Security Office (NHSO), Bangkok, Thailand

Suwat Chariyalertsak, Research Institute for Health Sciences (RIHES), Chiang Mai University, Chiangmai, Thailand

Nittaya Phanuphak, Thai Red Cross AIDS Research Centre, Bangkok, Thailand Duong Duc Bui, Viet Nam Administration of HIV/AIDS Control (VAAC), Ministry

of Health, Hanoi, Vietnam Seng Sopheap, National Centre for HIV/AIDS, Dermatology and STD

(NCHADS), Ministry of Health, Phnom Penh, Cambodia, Zunyou Wu, Ye Ma, Fujie Jang, National Center for AIDS/STD Control and

Prevention, Chinese Center for Disease Control and Prevention, Beijing, China Masami Fujita, WHO Cambodia, Phnom Penh, Cambodia Masaya Kato, WHO Vietnam Country Office, Hanoi, Vietnam Razia Pendse, WHO Regional Office for South-East Asia, New Delhi, India Dongbao Yu, WHO Regional Office for the Western Pacific Region, Manila,

Philippines

AcknowledgementsAcknowledgements

maximizing the prevention benefit of art in asia

Documents

number of hiv

hiv care

hiv transmission

hiv status

new hiv infections

health affairs

sexual health

ministries of health