Antiretroviral therapy in resource limited settings: Responding to the WHO 2010 guidelines

1. Antiretroviral therapy in resource limited settings: Responding to the WHO 2010 guidelines Sylvia Ojoo Assistant Clinical Professor of Medicine University of Maryland, Baltimore Country Director, UMB Programs/Kenya

2. Outline • Current status and progress of ART in RLS • Operational challenges to implementing revised WHO treatment guidelines • Recommendations for sustaining expansion of treatment while maintaining effectiveness

3. Current status: ART coverage averages 44% in SSA Zambia Number of people receiving ART in low- and middle-income countries, by region, 2002–2008 Botswana Source WHO: Towards universal progress report July 2010

5. Current status: patient clinical outcomes Retention on ART in low- and middle-income countries by region, 2008 Source WHO: Towards universal progress report July 2010 Source AIDSRelief Kenya Continuous Quality Improvement

6. Zambia Global summary of the AIDS epidemic, 2008 Total 33.4 million [31.1 – 35.8 million] Adults 31.3 million [29.2 – 33.7 million] Women (aged 15 and above) 15.7 million [14.2 – 17.2 million] Children under 15 years 2.1 million [1.2 – 2.9 million] Total 2.7 million [2.4 – 3.0 million]Adults 2.3 million [2.0 – 2.5 million]Children under 15 years 430 000 [240 000 – 610 000] Total 2.0 million [1.7 – 2.4 million]Adults 1.7 million [1.4 – 2.1 million]Children under 15 years 280 000 [150 000 – 410 000] Number of people living with HIV in 2008 People newly infected with HIV in 2008 AIDS-related deaths in 2008

7. 2010 WHO ART Guidelines – Key Recommendations

8. Many countries are adopting these recommendations • In 2010 among 38 countries with available data: • 34 countries in process of adopting CD4 threshold ≤ 350 cells/mm3 • 29 countries for all patients: Benin, Burkina Faso, Cameroon, CAR, Chad, China , Congo, Côte d'Ivoire, Eritrea, Ghana, Indonesia, Iran, Kenya, Lesotho, Malawi, Mali, Morocco, Moldova, PNG, Saudi Arabia*, Rwanda*, Seychelles*, Senegal, Swaziland, Tanzania, Togo, Ukraine, Zambia, Zimbabwe • 3 countries for pregnant women: Botswana (other patients CD4 ≤ 250 cells/mm3), South Africa (other patients CD4 ≤ 250 cells/mm3), DRC. • 2 countries are planning the adoption in 2011 : Burundi, Djibouti • 4 countries are in process of decision (by end 2010): • Ethiopia, India, Mozambique, Uganda Source: WHO survey 2010 on ARV use, June 1st, 2010

9. What have countries had to consider in implementing the guidelines?

10. 1. Increased number of patients needing treatment Malawi projections on treatment needs with and without the changes in guidelines. (Source: Dr ZenganiChirwa , Malawi MOH) • Increase in the number of patients who need treatment based on a lower threshold for treatment initiation (10-50%) • Impact on extant health systems and infrastructure

11. 2. HIV testing: the gap Source: MOH, Kenya

12. Knowledge of Status: Kenya AIDS Indicator Survey 2007 Treatment status of patients with CD4 <250 Source: MOH, Kenya

13. 3. Access to CD4 testing Median CD4 count at baseline count of 36 715 adults starting ART between 2001 and 2006 Current levels variable Malawi reporting about 20% Kenya 75% receiving baseline in 2007 Universal in countries like Botswana Countries anticipate significant investment in developing appropriate capacity and improving quality of tests Currently the majority of patients entering care already have low CD4 count

14. 4. Costs! Median annual cost of first-line ARV drug regimens in low-income countries by year, 2004–2008 > 34% of countries in SSA reported drug stock outs in 2008 Source WHO: Towards universal progress report July 2010

15. 5. Phasing out stavudine 1st line regimens used in 2.4 million adults in 36 low and middle income countries, December 2008 • “Dilemma over toxic HIV drug” • An Aids patient • takes her daily • dose of life-saving • anti-retroviral • (ARV) drugs. • Photos/FILE   • By ARTHUR OKWEMBAPosted Saturday, • December 5 2009  • Daily Nation http://www.nation.co.ke/News/-/1056/818128/-/vnkle7/-/index.html

16. Recommendations for sustaining expansion of treatment while maintaining effectiveness

17. 1. Resource mobilization and effective resource utilization • Effective utilization of extant resources from donors and bilateral partners • Governments to increase overall health expenditure (as per Abuja agreement) including that going into HIV care and treatment • Expand private HIV care services and private investment in health

18. 2. Effective approaches to HTC: e.g. family-centered testing Lwak Hospital, Nyanza 2009 • Each patient enrolled in the clinic has a family enquiry form filled • HIV test recommended and facilitated for all spouses and children < 15 yr • 8% of 125 children tested were HIV positive • 69% of 53 sexual partners tested were HIV positive • 31% of spouses in discordant partnerships • Better care and retention of non-ART patients Source; AIDSRelief CQI Program, Kenya 2009

19. 3. Improving the chronic care model • Accessible and usable patient care data • Clear patient care standards that cover the full range of effective prevention, care and treatment interventions that have been demonstrated to work • Chronic care model that puts community front and center Source: AIDSRelief Kenya CQI Program

20. 4. Health systems Greater integration of patient care services Institutionalization of gains made including chronic care paradigm Infrastructure to support guidelines including space and labs (CD4 with QA; Viral RNA services) Innovations! • Human resource capacity • Review legal and policy environment • Involvement of /leadership by institutions of higher learning • Effective pre-service preparation of HCWs • Development of innovative in-service support programs to allow effective dissemination of new practices etc • Management to support all health interventions at facility level

21. 5. Evidence based innovations Jaffar S, Amuron B, Levin J, et al.

22. Conclusion • Countries have been responsive and are committed to implementing the revised guidelines • Challenges that exist in doing this have been part of the landscape to varying degrees across countries since scale up began • If not addressed, sustainable expansion of services while maintaining quality may not be possible • These challenges are not insurmountable….