Addressing service delivery challenges and opportunities for the strategic use of ARVs in Thailand Professor Charles Gilks UNAIDS India National Consultation on the Strategic Use of ARVs Bangkok 9 – 10 th August 2012

Strategic use of ARVs in Thailand Key domains for strategic use of ARVs Treatment 2.0 Common service delivery challenges Domain-specific challenges

Key domains for Strategic use of ARVs in Thailand PMTCT Early ART PrEP for MSM

Treatment 2.0: Work streams I - Optimize drug regimens II – Promote diagnostics using point of care and other simplified technologies III – Reduce costs IV – Adapt delivery systems V – Mobilize communities, protect human rights

IV. Adapt Delivery Systems Decentralize services Integrate delivery systems : prevention, diagnosis and treatment Expand options for HIV testing and counselling in the health sector and at the community level as a gateway to access services As ART becomes simpler, expand task-shifting and use of primary health centres and community systems for delivery Shift from stand-alone ART services to integration with primary care, antenatal, maternal and child health, sexual and reproductive health and drug dependence services Strengthen procurement and supply systems to allow for increased number of patients and maintenance in community

The test-treat-retain cascade Pre-ART care and support Pre-ART care and support ART ART eligible HIV+ PrEP for target groups Couple Counselling

Task shifting Wider use of nurse-practitioners, community members and PLHIV expert patients / mentors will permit: Expansion and diversification of HIV testing Concrete interventions in the pre-ART window Support CTX and INH prophylaxis Roll-out of simpler ARV combinations for first- and second-line Provision of diagnostic tests and monitoring tools at point-of-care Innovative service delivery models to enhance ARV adherence and patient retention

V. Mobilize Communities Strengthen the demand side for treatment Engage communities in testing and counselling, service delivery, adherence and provision of care and support Ensure that human rights of all affected communities and people living with HIV are protected Achieve equity in access to treatment for all communities

Khayelitsha, South Africa: Facility-linked, PLWHA-led ‘Adherence Clubs' ClinicCommunity based Clubs Monthly doctor/nurse appointment allocated to one club Counselor and PWHLA “facilitator” Peer support Individual consultationGroup screening Time: 1 day in the clinic2 hours Monthly refills2-3 months refills General education, health talks Specific education & discussion 12 visits a year6 visits, with flexibility (family member can pick up meds)

PMTCT: opportunities and challenges HIV testing as standard of care in ANC settings Elimination goal equates to <2% transmission Simplify roll-out and consider option B+ Push couple counselling – Negative spouse: – Positive spouse:

Oral Pre-Exposure Prophylaxis: PrEP

HIV treatment simplification one pill once a day From Large pill burden and toxic regimes Emergency treatment (when sick) Doctor based, nurse supported Dependence on health facilities 5 million on treatment Treatment versus prevention Exponentially rising costs To: Low dose, long-acting, non-toxic regimes Early initiation and chronic care Nurse based, community worker supported Increased autonomy and adherence Task shifting Simpler SCM systems

Potential future areas for ART Optimization Simplification of tenofovir route synthesis Use of 3TC instead of FTC Reduced dosage of 3TC and EFV Substitution of EFV for Rilpivirine or NVPxr or Lersivirine TDF-FTC-EFV AZT-3TC + LPVr Reduced dose of AZT, 3TC and LPVr Substitution of 3TC for Apricitabine or Racivir or Elvucitabine Substitution of LPVr for ATVr or DRVr Substitution of AZT/3TC for integrase inhibitors (Raltegravir, Elvitegravir or GSK 572) Maintenance with PI monotherapy Substitution of RTV for cobicistat or SPI st Line 2 nd Line Use of co-blister packs

Fear of HIV DR is not a reason to hold back on TasP and further rapid treatment scale-up; Nor does it mandate intensive and routine laboratory monitoring; HIV drug resistance

Financing strategic use of ARVs in Thailand From Controlling the HIV epidemic with ARVs consensus statement IAPAC July 2012 Key importance of community activism political advocacy

Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS by 2015 Strategic use of ARVs will help Thailand achieve all 7 targets Target 1: Reduce sexual transmission of HIV by 50% by 2015 Target 2: Reduce transmission of HIV among people who inject drugs by 50% by 2015 Target 3: Eliminate mother-to-child transmission of HIV by 2015 and substantially reduce AIDS-related maternal deaths Target 4: Have 15 million people living with HIV on antiretroviral treatment by 2015 Target 5: Reduce tuberculosis deaths in people living with HIV by 50% by 2015 Target 6: Reach a significant level of annual global expenditure (US$ billion) in low-and middle- income countries Target 7: Mobilize critical enablers and synergies among development sectors