The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact

1. The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO

2. Getting to Zero mortality Getting to Zero mortality • Taking stock: How close is Asia to zero HIV-related deaths? • Identifying current bottlenecks and response gaps • Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment • Looking ahead: current and future opportunities

3. Getting to Zero mortality Getting to Zero mortality • Taking stock: How close is Asia to zero HIV-related deaths? • Identifying current bottlenecks and response gaps • Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment • Looking ahead: current and future opportunities

4. Adult ART coverage in Asia is below the global average for low- and middle-income countries Proportion of eligible adults living with HIV receiving ART, by region, 2009–2012 64% 51% Source: UNAIDS/WHO Coverage: number of adults receiving ART in 2012 / number of adults eligible for ART in 2012 according to 2010 guidelines.

5. Great variability in access to ART in Asia ART coverage in selected Asian countries, 2012 Source: UNAIDS/WHO Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines

6. HIV-related deaths have decreased in Asia, but less than globally (in LMICs) Peak: 2005 30% 20% Source: UNAIDS/WHO

7. Getting to Zero mortality • Taking stock: How close is Asia to zero-AIDS related deaths? • Identifying current bottlenecks and response gaps • Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment • Looking ahead: vision and opportunities for the future

8. Still too many people start ART late Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010 In Asia, 1 in 3 patients started ART at CD4<100* in 2010 Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam

9. Too many people are not aware of their HIV status Cascade of HIV diagnosis to viral suppression, China, 2012 Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

10. Key populations: too many unaware of their HIV status Percentage of key populations who received an HIV test in the last 12 months and know their results % 52% 41% 33% Source: WHO, 2013

11. Too many people are lost to care after diagnosis Cascade of HIV diagnosis to care, Vietnam, 2012 Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

12. Still too many people are lost from ART: Retention at 12, 24 and 60 months Still too many people are lost from ART: Retention at 12, 24 and 60 months % Source: WHO/UNAIDS

13. Are the optimal regimens being used? • 44 different first-line regimens • 119 different second-line regimens • 30% of patients still on d4T • Only 18% of patients on TDF % Proportion of d4T and TDF among adult patients on 1st line ART by end of 2012 Source: WHO ARV Use Survey, 2013

14. Still too many people who: - do not know their HIV status - start ART late - take sub-optimal regimens - are lost to follow-up - do not have access to comprehensive package of care services Important challenges in Asia • Key populations require tailored approaches • and service models

15. Getting to Zero mortality • Taking stock: How close is Asia to zero-AIDS related deaths? • Identifying current bottlenecks and response gaps • Towards greater impact: The 2013 Consolidated ARVs Guidelines – earlier, better, and simpler treatment • Looking ahead: current and future opportunities

16. Earlier treatment initiation • Threshold moved to < 500 CD4 (adolescents, adults, MSM, TG, SW, PWID) • Priority for reaching all HIV+ symptomatic persons and those with CD4 < 350 • CD4-independent situations for ART initiation: • HIV/TB coinfection and HBV advanced liver disease • HIV serodiscordant couples • Pregnancy: “options B/B+” • Children less than 5 years of age

17. Simpler and better treatment: one regimen for all Preferred 1st line regimen: TDF + 3TC (or FTC) + EFV • Harmonize regimens : Adults, Pregnant Women (1st trimester), Children >10 years, TB and Hepatitis B • Simplicity: effective, well tolerated, once-daily FDC facilitates adherence • Streamlines drug procurement and supply chain management • Affordability: cost declined significantly since 2010

18. Improved monitoring of ART Response • Key objective: earlier identification of treatment failure

19. Expanded HIV testing and counselling • Provider-Initiated Testing and Counselling (PITC) • Community-based testing (June 2013) • HIV Self testing (HIVST) • FDA (USA) approval of OraQuick for HIVST • (July 2012) • Evolving approach, particularly relevant for key populations • Legal, ethical, and public health implications

20. Countries are already moving: CD4 threshold for ART initiation Likely changes National policies as of August 2013 Number of countries surveyed: 16 * As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions

21. Countries are already moving: PMTCT – move to option B or B+ Likely changes National policies as of August 2013 Number of countries surveyed: 16 * As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions

22. Major reduction in mortality expected Estimated annual HIV-related deaths -39% Source: Special analysis conducted by Futures Institute, 2013

23. Getting to Zero mortality • Taking stock: How close is Asia to zero-AIDS related deaths? • Identifying current bottlenecks and response gaps • Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment • Looking ahead: current and future opportunities

24. The path towards “Zero deaths” Innovate Research and develop Scale up Testing and ART to all people living with HIV Drugs Preventive vaccine Focus on key populations Diagnostics Linkages and retention Cure Service delivery models Comprehensive care models

25. The path towards “Zero deaths” Innovate Research and develop Scale up Testing and ART to all people living with HIV Drugs Preventive vaccine Focus on key populations Diagnostics Linkages and retention Cure Service delivery models Comprehensive care models

26. The path towards “Zero deaths” Innovate Research and develop Scale up Testing and ART to all people living with HIV Drugs Preventive vaccine Focus on key populations Diagnostics Linkages and retention Cure Service delivery models Comprehensive care models

27. Potential strategies to cure HIV Source: IAS

28. Conclusions: the way forward • 1. Implement new ARV Guidelines: earlier, better, simpler ART • 2. Focus on key populations: community-based models for testing; comprehensive care • Enhance service quality and integration for broader and sustained impact. • Lead Innovation and Increase Investments

29. Rachel Baggaley, Andrew Ball, Jhoney Barcarolo,Michel Beusenberg, Meg Doherty, Nathan Ford, Vincent Habiyambere, Ying-Ru Lo, Amaya Maw-Naing, Razia Pendse, Jos Perriens, Nathan Shaffer, Marco Vitoria, Gundo Weiler Acknowledgements