Download Team Name - IAS 2013

Maximizing the Prevention Benefit of
ART in Asia
Ying-Ru Lo, MD, DTM&H
World 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
Content
 Epidemiology and new evidence
 Programmatic challenges
 Conclusions
2|
World Health
Organization
Western Pacific Region
Estimated no. of PLHIV by region, 2011
25,000,000
Estimated no. of PLHIV
20,000,000
Asia bears the 2nd highest
burden of HIV (4.9 million of
global total of 34 million)
15,000,000
10,000,000
5,000,000
0
SubSaharan
Africa
Source: GARP 2012
3|
East
South
and
SouthEast Asia
Latin
America
&
Caribean
Europe
and
Central
Asia
Middle
East and
North
Africa
Oceania
World Health
Organization
Western Pacific Region
ART coverage in selected countries in
Asia, 2011
All ages
100%
95%
Only 1 country reached > 80% coverage
90%
% ART coverage
80%
58%
60%
53%
50%
51%
43%
38%
40%
37%
32%
31%
30%
71%
68%
70%
24%
27%
24%
21%
20%
10%
0%
Source: GARP 2012
4|
By the end of 2012 number of people receiving ART
• Globally, 9.6 million (64% of global target)
• In Asia, 1.3 million
Country
World Health
Organization
Western Pacific Region
Evidence 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
5|
World Health
Organization
Western Pacific Region
Modelling suggests that HIV testing and
ART can avert new HIV infections in Asia
 China
 10-fold increase in ART could decrease the number of HIVrelated 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)
6|
World Health
Organization
Western Pacific Region
A combination of interventions has
greater impact than an intervention
delivered alone
7|
World Health
Organization
Western Pacific Region
Effect of ART at population level
depends on ……..
 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
8|
World Health
Organization
Western Pacific Region
Metrics to monitor efficiency of the
treatment cascade
China 2011
% of people living with HIV
% of people living with HIV
Vietnam 2011
Source: UNAIDS 2012, VAAC 2011
Source: UNAIDS 2012, NCAIDS 2011
 People with HIV do not know their status
 Loss of individuals from HIV testing to care and ART
9|
World Health
Organization
Western Pacific Region
Treatment cascade, Cambodia 2012
Estimated # PLHIV 74,572* (100%)
# HIV tested ? ? ?
# on ART 48,913 (66%)
# in HIV care
6587 (9%)
* 2011 Estimates
Source: NCHADS 2012
• Increasing # of individuals who know
their HIV status
• Invest in monitoring
10 |
World Health
Organization
Western Pacific Region
Treatment cascade, Thailand, 2008-2011
No. of people
250,000
2008
2010
200,000
150,000
100,000
??
2009
2011
71% viral load
suppression with
> 6 months on ART
50,000
0
Source: Adapted from Bhakeecheep (Personal Communication), National Health Security Office Thailand 2012
11 |
World Health
Organization
Western Pacific Region
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
12 |
World Health
Organization
Western Pacific Region
Note 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
13 |
World Health
Organization
Western Pacific Region
2012
 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)
14 |
World Health
Organization
Western Pacific Region
Monitoring adverse events during earlier
ART
 HIV drug (antiretroviral) resistance
 impact of longer treatment required for earlier ART on
resistance is unknown
 monitor early warning indicators
 Adverse drug reactions
 Risk behavior compensation (WEPDB0105, Doyle et al;
MOLBPE30, Bavinton et al)
15 |
World Health
Organization
Western Pacific Region
Low levels of transmitted HIV drug
resistance in Asia, 2005-2010
% 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
2005
2006
2007
2008
2009
2010
1.0
1.3
3.3
2.9
…
1.0
SouthEast Asia
(0.6-4.0) (0.1 - 3.5) (2.8-18.9) (0.6-8.2)
Western
Pacific
1.8
(0.2-4.5)
3.3
1.9
(1.0-6.6) (0.6-3.7)
4.0
5.6
(0.0-5.8)
0.0
(1.6-8.2) (3.2-8.7) (0.0 -16.1)
Pvalue
NS
NS
NS: Not statistically significant.
Source: WHO HIV Drug Resistance Report 2012.
16 |
World Health
Organization
Western Pacific Region
HIV drug resistance surveillance
 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
17 |
World Health
Organization
Western Pacific Region
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
18 |
World Health
Organization
Western Pacific Region
Planned implementation research (January 2013)
Thailand
Indonesia
Cambodia
Vietnam
China
Population
MSM
MSM
IDU++
All SD couples
All SD couples
IDU++
All SD couples
MARPs
Treat 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 CD4
TDF-based
Irrespective
CD4
TDF-based
Irrespective
CD4 or
CD4<500
Irrespective
CD4
TDF-based
(possibly FDC)
Irrespective
CD4
TDF
NGO and public
services for
MSM and IDU
HTC
ART
HTC
Methadone
sites
Pre ART
HTC
ART
Outreach
internet
peers
Inter-country workshop on optimizing HIV treatment through
Enrollment
the Treatment 2.0 Initiative, Yangon, Sept 13-14, 2012
Challenges
 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
20 |
World Health
Organization
Western Pacific Region
Treatment as (for) Prevention
Gathering necessary information to inform
programmes and WHO guidelines
Serodiscordant
couples &
programmatic
update

Metrics

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
Implementation
& scale-up in
countries

Impact
evaluation
How to improve efficiency of the HIV
testing, care and treatment cascade?
• WPRO metrics workshop
• Support to implementation research in countries
• Piloting Unique Identifier Codes
• WHO 2013 Guidelines: The
use of ARVs for Treating
and Preventing HIV
2012
21 |
2013
2014
2015
World Health
Organization
Western Pacific Region
Acknowledgements
 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
22 |
World Health
Organization
Western Pacific Region