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Accelerating Anti-Retroviral Treatment as a catalytic action for Ending AIDS

Accelerating Anti-Retroviral Treatment as a catalytic action for Ending AIDS. Pride Chigwedere , MD, PhD Senior Advisor to the African Union. AWA CONSULTATIVE EXPERTS’ COMMITTEE MEETING OF COMMISSION OF THE AFRICAN UNION, NOUAKCHOTT, MAURITANIA 27-28 MAY 2014. Calls for Ending AIDS.

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Accelerating Anti-Retroviral Treatment as a catalytic action for Ending AIDS

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  1. Accelerating Anti-Retroviral Treatment as a catalytic action for Ending AIDS Pride Chigwedere, MD, PhD Senior Advisor to the African Union AWA CONSULTATIVE EXPERTS’ COMMITTEE MEETING OF COMMISSION OF THE AFRICAN UNION, NOUAKCHOTT, MAURITANIA27-28 MAY 2014

  2. Calls for Ending AIDS • Continental Calls • Abuja + 12 Special Summit • Common African Position for Post-2015 Agenda • Global Calls • MDGs • 2011 Political Declaration • Is it possible to End AIDS? • Progress in last decade • Interventions available

  3. 2011 UNGA Political Declaration - 2015 targets 3 5 4 1 2 Eliminate new HIV infections among children and halve AIDS-related maternal deaths Halve sexual transmission 15 million people on HIV treatment Halve infections among injecting drug users Halve tuberculosis deaths among people living with HIV 7 10 9 8 6 Close the global resource gap and achieve annual investment of US$ 22-24 bn Eliminate gender inequalities and sexual violence and increase capacities of women and girls Eliminate parallel systems, for stronger integration Eliminate stigma and discrimination Eliminate travel related restrictions

  4. A focus on treatment is strategic

  5. HIV treatment can normalize survival Expected impact of HIV treatment in survival of a 20 years old person living with HIV in a high income setting (different periods)

  6. Dramatic impact of HIV response on life expectancy years 70 60 50 40 1960 1970 1980 1990 2000 2010 Source: World Bank life expectancy data Slide courtesy D Birx, PEPFAR

  7. Efficacy of Major Biomedical Interventions for Sexual Transmission of HIV ART in HIV+ partner (HPTN 052) 96% (72 - 99) Male circumcision (Orange Farm, Rakai, Kisumu) 57% (42 - 68) PrEP (iPrEx - oral tenfovir/emtricitabine) 44% (15 - 63) STD treatment (Mwanza) 42% (21 - 58) Microbicide* (CAPRISA 004 - tenofovir gel) 39% (6 - 60) HIV Vaccine* (Thai RV144) 31% (1 - 51) Efficacy (%) 0 10 20 30 40 50 60 70 80 90 100 * These interventions are not yet available. Source: Adapted from Padian et al, 2010; Abdool Karim, 2010; Grant et al , 2010; Cohen et al, 2011

  8. Reducing viral loads to 100/mL reduces HIV transmission by 99% 1.00000 0.10000 Transmissions per year 0.01000 0.00100 0.00010 0.00001 1 000 000 100 000 10 000 1 000 100 10 Viral load / mL Source: Attia 2009 AIDS

  9. A clear correlation between HIV treatment and incidence 1.1% (0.8%-1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage. 1.0 p=0.325 p=0.003 0.8 p=0.0001 p=0.013 Incidence rate ratio 0.6 0.4 0.2 ART & HIV incidence: Hlabisa, South Africa 0 0% 30% 60% ART coverage Source: Tanseret al. Science 2013;339:966-971

  10. Reducing the community viral loaddrives down acquired resistance to ARVs 90% 0.20 Incidence of acquired resistance (per year) Suppressed viral load (<50/mL) 0.10 80% 0.04 70% 0.02 1995 2008 0.01 60% Source: Gill et al. 2010 Clinical Infectious Diseases

  11. Expanding access to ART is a smart investment: Case of South Africa Source: Expanding ART for Treatment and Prevention of HIV in South Africa: Estimated Cost and Cost-Effectiveness 2011-2050. PLoS ONE 7(2):e30216

  12. Significantly higher employment at CD4≥500 among adults • Compared to CD4<200, CD4≥500 associated with • 5.8 more days/month • 2.2 more hours/day (40% more than ref. mean of 5.5) • Linear regression model with age, age-squared, and sex included as controls • ** p<0.05, * p<0.10 • Reference group has CD4<200 Those with CD4≥500 worked nearly 1 week/month more than those with CD4<200, and as much as HIV-uninfected adults Source: Thirurmurthy, Health Affairs, 2012

  13. Rapid Treatment Scale up … • Prevents death • Prevents active disease e.g. TB • PMTCT of HIV: Option B+ • Prevents new HIV infection • Saves money and increases productivity • Lays the foundation for the end of the AIDS epidemic

  14. Scenarios of ARV eligibility: WHO vision Source: WHO 2014

  15. Gap in antiretroviral coverage varies within Africa 7.6 million people on ART in Africa 21.2 million eligible under WHO 2013 Guidelines 25 million people living with HIV on continent Source: UNAIDS estimates 2013

  16. UNAIDS PCB calls for new targets • Targets drive progress • New scientific evidence • Post 2015 • Accountability • A winnable challenge

  17. Country and regional track: regional retargeting consultations

  18. Continental AUC led processes • July 2013 – Abuja + 12 Special Summit • Nov 2013 – AUC/RECs Coordination Meeting • Mar 2014 – Inter-Agency Meeting on AIDS • May 2014 – AWA Experts Meeting • June 2014 – AWA HoS Action Committee

  19. Global track

  20. Treatment cascade Notes: No systematic data are available for the proportion of people living with HIV who are linked to care, although this is a vital step to ensuring viral suppression in the community. Sources: 1. UNAIDS 2012 estimates; 2. Demographic and Health Surveys, 2007–2011 (www.measuredhs.com); 3. Kranzer, K., van Schaik, N., et al. (2011), PLoS ONE; 4. GARPR 2012; 5. Barth R E, van der Loeff MR, et al. (2010), Lancet Infect Disease.

  21. The treatment target 90% 90% 90% • virally suppressed tested on treatment

  22. Challenges: Translating Science into Action • What is the RIGHT thing to do? Question of Science • Can I choose to do the RIGHT thing? Constrained or competing choices (Economic and Political Feasibility) • Now that I have chosen the RIGHT thing, can I actually do the RIGHT thing RIGHT? Question of implementation • Did everything turn out all RIGHT? Outcomes

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