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

Pride Chigwedere, MD, PhDSenior Advisor to the African Union

AWA CONSULTATIVE EXPERTS’ COMMITTEE MEETING OF COMMISSION OF THE AFRICAN UNION,

NOUAKCHOTT, MAURITANIA27-28 MAY 2014

Calls for Ending AIDS

• Continental Calls Abuja + 12 Special SummitCommon African Position for

Post-2015 Agenda

• Global Calls MDGs2011 Political Declaration

• Is it possible to End AIDS?Progress in last decadeInterventions available

2011 UNGA Political Declaration - 2015 targets

1

Halve sexual transmission

2

Halve infections among injecting drug users

3

Eliminate new HIV infections among children and halve AIDS-related maternal deaths

4

15 million people on HIV treatment

5

Halve tuberculosis deaths among people living with HIV

10

Eliminate parallel systems, for stronger integration

9

Eliminate travel related restrictions

8

Eliminate stigma and discrimination

7

Eliminate gender inequalities and sexual violence and increase capacities of women and girls

6

Close the global resource gap and achieve annual investment of US$ 22-24 bn

A focus on treatment is strategic

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

HIV treatment can normalize survival

Dramatic impact of HIV response on life expectancy

Source: World Bank life expectancy data

Slide courtesy D Birx, PEPFAR

70

60

50

40

years

1960 1970 1980 1990 2000 2010

Efficacy of Major Biomedical Interventions for Sexual Transmission of HIV

Efficacy (%)

STD treatment (Mwanza)

Male circumcision (Orange Farm, Rakai, Kisumu)

HIV Vaccine* (Thai RV144)

Microbicide*(CAPRISA 004 - tenofovir gel)

PrEP (iPrEx - oral tenfovir/emtricitabine)

ART in HIV+ partner(HPTN 052)

42% (21 - 58)

57% (42 - 68)

31% (1 - 51)

39% (6 - 60)

44% (15 - 63)

96% (72 - 99)

1009080706050403020100

* These interventions are not yet available. Source: Adapted from Padian et al, 2010; Abdool Karim, 2010; Grant et al , 2010; Cohen et al, 2011

Reducing viral loads to 100/mL reduces HIV transmission by 99%

Tran

smis

sion

s pe

r yea

r

0.10000

0.01000

0.00100

0.00010

0.00001

1.00000

101001 00010 000100 0001 000 000

Viral load / mLSource: Attia 2009 AIDS

A clear correlation between HIV treatment and incidence

Source: Tanser et al. Science 2013;339:966-971

1.1% (0.8%-1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage.

ART & HIV incidence: Hlabisa, South Africa

p=0.325p=0.003

p=0.013p=0.0001

Inci

denc

e ra

te ra

tio

1.0

0.8

0.6

0.4

0.2

0

ART coverage0% 30% 60%

Reducing the community viral loaddrives down acquired resistance to ARVs

Inci

denc

e of

acq

uire

d re

sist

ance

(per

yea

r)

Sup

pres

sed

vira

l loa

d (<

50/m

L)

1995

0.20

0.10

0.04

0.02

0.01

90%

80%

70%

60%

2008

Source: Gill et al. 2010 Clinical Infectious Diseases

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

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

Regression model coefficients(1) (2)

Outcome:Days worked in the

past monthHours worked on usual day in past

CD4<200 Reference ReferenceCD4 200-349 2.7 1.8CD4 350-499 4.8 0.9CD4 ≥500 5.8** 2.2*Observations 107 107

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

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

Scenarios of ARV eligibility: WHO vision

Source: WHO 2014

Source: UNAIDS estimates 2013

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

UNAIDS PCB calls for new targets

• Targets drive progress• New scientific evidence• Post 2015• Accountability• A winnable challenge

• 31 March-1 AprilWCA

• 24-25 AprilMENA• 23-24 April, 26-28 MayLA&CAR• 28-29 AprilEECA• 19-20 MayESA• 11-12 JuneAP

Country and regional track: regional retargeting consultations

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

Global trackPolitical stream

AU Partners Forum, 5-7 March

Vancouver TasP workshop political

day: high-level roundtable, 1 April

AIDS 2014: High-level panel, 20 July

Technical stream

Treatment 2015 Advisory

Committee meeting, 3 April

Price tag for the next targets, 7-8

April

Face-to-face meeting of the

UNAIDS Treatment Community, TBD,

June

Thematic stream

Treatment among young people and adolescents, 16-17

April

The perspective of the civil society on

the next targets, 14-15 May

The next paediatric treatment targets,

10-11 June

The Role of Laboratory

Medicine in the next treatment

targets, 16-17 June

Treatment cascade

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.

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 .

The treatment target

90% 90% 90%

tested on treatment virally suppressed

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