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90-90-90 and Conception

90-90-90 and Conception. 2017 IAS Conception Meeting Paris, France July 25th, 2017. Reuben Granich, MD, MPH Somya Gupta MA International Association of Providers of AIDS Care (IAPAC). Disclosures. No Gilead Funding No Gates Foundation Funding No Research Trial funding. Outline.

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90-90-90 and Conception

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  1. 90-90-90 and Conception 2017 IAS Conception Meeting Paris, France July 25th, 2017 Reuben Granich, MD, MPH Somya Gupta MA International Association of Providers of AIDS Care (IAPAC)

  2. Disclosures • No Gilead Funding • No Gates Foundation Funding • No Research Trial funding

  3. Outline • Women and HIV • HIV Policy work • Global 90-90-90 status report • Conclusions

  4. CD4+ cell count Mortality at one year HIV-positive 100x 3.9x 2.5x HIV-negative HIV+ and HIV- post-partum women in Harare (1997-2000) Treatment matters Data: Hargrove AIDS 2010; Model: Williams JID 2006.

  5. HIV treatment reduces viral load and heterosexual transmission (2003) Quinn et al. NEJM. 2003;342(13):921-929.

  6. Apollo 13 strategy: “Working the Ending AIDS problem” • Set clear and shared goals • Change business as usual • Establish accountability and use open data • Accelerate pace of science to service delivery • Budget for success • Leadership on goals, priorities, execution and accountability Failure is not an option!

  7. Global HIV Status Report (2015/16) Half full: • 19.5 million on ART (50%) • ~70% of PLHIV know status • 19 billion USD per year • TB among PLHIV down 32% from 2005 Half empty: • 1.8 million infections per year • 37 million PLHIV • 1 million HIV deaths • 1.2 million HIV/TB illnesses • 400,000 HIV/TB deaths Half full, half empty?.... it’s still half! Source: UNAIDS Fact Sheet. http://www.unaids.org/en/resources/fact-sheet

  8. Global access to HIV treatment, 2010-2016 81% Treatment gap On ART

  9. Reported and projected people on ART 32 mn (81%) 27 mn (69%) 19.5 mn (53%) 8 mn (23%)

  10. Answer:One policy for polio eradication using tOPV Can anyone tell me what policy this WHO map is showing? Source: MMWR July 3, 2015

  11. ART initiation for asymptomatic people Guidelines from 127 countries Source: published policy

  12. ART initiation for asymptomatic people 2015 WHO Recommendation : Irrespective of CD4 count <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count 58 countries or 81% of burden Source: published policy July 2017

  13. ART initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count <200 <350 <500 Irrespective of CD4 count Source: published policy July 2017

  14. ART initiation for pregnant women Source: published policy

  15. Policy Lag in LMICs (85 countries) Data as of July, 2017

  16. 90-90-90 and Continuum of Care Targets 90% 90% 90% Know status On treatment Virally suppressed 90% 81% 73%

  17. People living with HIV diagnosed positive (2010-2017) UNAIDS target 90% 90%-100% 70-89% Below 70% Data not available Incomplete or no continua People living with HIV diagnosed positive (Target 90%) 85 (77% global HIV burden in 2016) with complete care continua

  18. Mapping on ART and viral suppression 90-90-90 targets (85 countries) ART coverage >81% and viral suppression >73% ART coverage 60-80% and viral suppression50-72% ART coverage <60% and viral suppression <50% Incomplete or no continua 85 countries with complete care continua

  19. Proportion of people living with HIV diagnosed and on ART TARGET UNAIDS target: 81% UNAIDS target: 90% 87 countries with data on 1st and 2nd 90

  20. Proportion of people living with HIV on ART and with viral suppression TARGET UNAIDS target: 73% UNAIDS target: 81% 85 countries with complete care continua

  21. Documenting and grading continua methods

  22. Next generation cascades... • Key populations (MSM, FSW, PWID) • HIV and TB • Pediatric • Sub-national • Fast Track Cities • Age categories • Pregnant women and children

  23. MSM living with HIV virally suppressed (Target: 73%) 73%-100% 50-72% Below 50% Data not available

  24. Age category cascades allow for improved focus

  25. ART coverage among adolescents and young adults (15-24 years) in 10 countries 90-90-90 target: 81% 84% 77% 70% 68% 71% 64% 61% 34% 40% 32% Blue bars show ART coverage among adolescents and young adults (2012-2017 data) while red lines show national ART coverage among all PLHIV. UNAIDS 90-90-90 target for 2020 is 81% ART coverage.

  26. Viral suppression among adolescents and young adults (15-24 years) in 8 countries 79% 90-90-90 target: 73% 63% 61% 59% 51% 25% 29% Blue bars show viral suppression among adolescents and young adults (2012-2017 data) while red lines show viral suppression among all PLHIV. UNAIDS 90-90-90 target for 2020 is 73% viral suppression. Data unavailable for Cameroon and Ethiopia.

  27. HIV, TB and HIV/TB: New cascade

  28. Phases of HIV Epidemic 1980-2020 Discovery End of AIDS Devastation • 1981 AIDS • 1983 HIV • 1983 WHO surveillance • 1983 Denver Principles • 1985 HIV test • 1987 AZT • 1987 WHO GPA • 1987 TASO • Uganda • 1985 Reagan • mentions AIDS • 1986 AIDS Quilt • 1986 ACT-UP • 1992 AIDS #1 killer US men 25-44 years old • 1993 US Office of National AIDS Policy • 1994 AZT to prevent MTCT • 1995 Protease inhibitor • 1996 Vancouver triple therapy • 1996 US home HIV test • 1997 AIDS deaths decline 40% in US • 1998 TAC South Africa • 2001 • Special UN Session “global emergency” • 2002 Leading cause of death • 2002 • Global Fund established • 2003 • PEPFAR • 2003 • WHO 3x5 2005 1st generic ARVs 2005 Circumcision RCTs 2006 TasP proposed as HIV control strategy 2008 Swiss statement 2009Attiametaanalysis ART prevents transmission 2009 WHO proposes using treatment to eliminate HIV • 2011 • HPTN 052 proves ART blocks transmission • 2012 PrEP approved in US • 2010 UNAIDS Treatment 2.0 with treatment as prevention • 2014 UNAIDS90-90-90 targets • 2015 Fast Track Cities with 60+ cities • 2015 STAR and TEMPRANO • 2015 HealthGap access to treatment is human right • 2016 18.2 M (49%)people on treatment • 2016 Cumulative 39 million AIDS deaths • 2020 • 90-90-90 reached • 2020 • 95-95-95 targets affirmed 2020 37M PLHIV 27 (81%) Tx 1980 100,000 PLHIV No treatment (Tx) 1985 Nearly million PLHIV No treatment 1990 Millions PLHIV No treatment 1995 20M PLHIV No Tx 2000 34.3M PLHIV 1M (3%) Tx Africa 50,000 (2%) 2010 33.3M PLHIV 7.5M (23%) treatment 2015 36M PLHIV 16M (44%) Tx 2005 40.3M PLHIV 2M (5%) Tx Policy Hit early, hit hard. Almost no access to treatment in low and middle income countries 2009 WHO CD4 <350 2012 US Treat All 2013 WHOCD4 <500 2015 WHO Irrespective CD4 2003 WHO CD4 <200 Granich Lancet 2017

  29. Ending AIDS as a major public health problem Feasible: “capable of being done or carried out” --Merriam-Webster’s Dictionary

  30. Thank you HIV 90-90-90 watch www.HIV90-90-90watch.org HIV Policy Watch www.HIVpolicywatch.org

  31. Leadership matters

  32. You get what you pay for..... Spending on ART 75% Number of countries 3/4 of the countries spend less than 26% of HIV budget on ART Proportion of HIV budget Williams, unpublished data, UNAIDS GARPR database 2014

  33. Proportion of HIV spending on care and treatment, HIV spending on care and treatment per PLHIV

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