WHO 2016-2021 HIV strategy and guidelines support reaching 90-90-90

1. The last 90:WHO recommendations to improve adherence, retention and viral load suppressionWHO TREAT ALL SATELLITEDr. Tsitsi ApolloDurban, 18 July 20167

2. WHO 2016-2021 HIV strategy and guidelines support reaching 90-90-90 90% tested 90% treated 90% suppressed

3. Losses prior to starting ART 2004-2014 • Data from • 5 regions • 25 countries • 600,000 patients • Losses high among • Adolescents Source: IeDEA-WHO 2015

4. Linkage to HIV care and initiation ART Following a positive diagnosis, a package of supportive interventions should be offered to ensure timely linkage to HIV care. (Strong, moderate) Interventions for improved linkage and engagement in HIV care. • Streamlined interventions to reduce time between diagnoses and engagement in HIV care, including • enhanced linkage with case-management • support for HIV disclosure • client tracing • training health workers to provide multiple services • streamlined package of services • Peer support & navigation approaches for linkage. • Quality improvement approaches: use of data, and context specific interventions

5. Treatment Adherence: Challenges • Multiple adherence barriers • Forgetting • Travel and migration • Change to routine • Distance to clinic • Stock-outs IAS 2016. Abstract THPEB074

6. WHO Rec: Treatment adherence Adherence support interventions should be provided to all people on ART (strong, moderate) Interventions that demonstrated effectiveness: • Peer counsellors • Mobile phone text messages • Reminder devices • Cognitive behavioural therapy • Behavioural skills training /medication adherence training • Fixed dose combinations and once daily regimens

7. FDC: pooled adherence

8. Retention: Challenges <50% retained in care by 5 years* IeDEA-WHO Collaboration 2015 * Losses include transfers and deaths

9. WHO Rec: Retention in care Programmes should provide community support for people living with HIV to improve retention in HIV care (strong, low) Interventions: • Package of community based interventions -- Multi-faceted, community-based lay CHWs/ “patient advocates” providing adherence, treatment and psychosocial support • Adherence clubs and peer groups providing patient support: postpartum and breastfeeding women, children, key population, adolescents, men • Extra care for high-risk persons

10. Frequency of clinic and ARV pickup visits • Less frequent clinical consultation visits (3-6 months) • Less frequent medication pick up visits • (3-6 months) • Trained and supervised lay providers can distribute ARV in community settings for children, adolescents and adults living with HIV

11. Summary of the evidence – Less frequent clinic visits • Mortality • Very low quality evidence of comparable risk of mortality among less frequent clinic visits (OR: 1.12, 95% CI: 0.60 – 2.10) • Morbidity • Low quality evidence of protective effect of less frequent clinic visits on morbidity (OR: 0.61, 95% CI: 0.35 – 1.05) • Retention • Very low quality evidence of significantly increased odds of retention with less frequent clinic visits (OR: 1.90, 95% CI: 1.21 – 2.99) • Adherence • Very low quality evidence of non-significant increased odds of being adherent with less frequent clinic visits (OR: 2.00, 95% CI: 0.53 – 7.90) • Viral failure • Low quality evidence of non-significant protective effect of less frequent clinic visits on viral failure (OR: 0.83, 95% CI: 0.51 – 1.36)

12. Summary of the evidence: Less frequent ARV pick ups • Retention • Very low quality evidence of non-significant increased odds of retention among less frequent pick-ups (OR: 1.93, 95% CI: 0.62 – 6.04) • Adherence • Very low quality evidence of non-significant increased odds of being adherent among less frequent pick-ups (OR: 2.00, 95% CI: 0.53 – 7.60) • Viral failure • Very low quality evidence of slight non-significant increased odds of viral failure among less frequent pick-ups (OR: 1.03, 95% CI: 0.60 – 1.78)

13. Lay providers distributing ARVs in community settings Moderate quality evidence no difference of death, loss to follow up, virologic failure compared to those receiving care in facility (2 cluster randomized studies) Mortality Loss to follow up Virologic suppression

14. 2013: Recommendations for task shifting • Not yet fully implemented: • Nurses, midwives, non-physician clinicians can initiate and maintain first-line ART • Community health workers can distribute ARVs between clinic visits • HIV care and ART can be initiated and maintained at health centre level; and maintained at community level

15. WHO: New Task shifting good practice statements Good practice statement Trained and supervised non-laboratory staff including lay persons can undertake blood finger prick testing and carry out POC diagnostic tests. Trained and supervised lay providers can distribute ART in the community Trained and supervised lay providers can provide HIV testing

16. WHO recs: Viral Load • Viral load is recommended as the preferred approach to diagnose and confirm treatment failure • Viral load failure is defined as persistent viral load > 1000 copies/ml • Viral load should be measured at 6M, 12M then every 12M (conditional, very low) • Dried blood spots can be used to determine viral load (conditional, low)

17. Viral Load Challenges: policy into practice Routine viral load is fully implemented in 47% of LMIC and partially implemented in 26% of LMIC.

18. Summary of key messages • Adopt differentiated care/services tailored to need of PLHIV • Prevent delayed ART initiation and patient attrition • Strengthen the care continuum through evidence based interventions for adherence and retention • Smartly integrate services, provide people-centred quality care using data for service improvement • Take viral load to scale