ICASA |1 | LEARNING FROM “B+” IMPLICATIONS FOR IMPLEMENTING “TREAT ALL” Dr. Gottfried Hirnschall WHO, Geneva ICASA Harare, December 2015

“Option B+” has been one of the most widely adopted of all WHO recommendations B+ policy adopted in 80% of 144 LMIC surveyed Among the countries of the Global Plan, B+ has been implemented in over 90%

ART should be initiated among all adults with HIV regardless of WHO clinical stage and at any CD4 cell count strong recommendation, moderate-quality evidence As a priority, ART should be initiated among all adults with severe or advanced HIV clinical disease (WHO clinical stage 3 or 4) and adults with CD4 count ≤350 cells/mm 3 strong recommendation, moderate-quality evidence For the first time in the history of ARV guidelines… –we will see ONE recommendation for everyone –We will erase the distinction between pregnant women and everybody else that has long contributed to poor ART access for women who happen to be pregnant WHO 2015 ARV guidelines recommend “TREAT ALL”

Lessons from B+ to implement “Treat All” B+ has created a paradigm shift in service delivery –in many countries all MCH clinics are now providing ART –HOW CAN WE LEARN FROM THIS AND USE THE B+ APPROACH TO DELIVER DECENTRALIZED UNIVERSAL ART TO ALL? Many B+ programs initiate ART on the same day as HIV is diagnosed –WHAT DOES B+ TELL US ABOUT SAME-DAY ART START AND WHAT IT MEANS FOR PROGRAMS CONSIDERING UNIVERSAL ART FOR ALL Retention especially post partum retention has been a challenge for many B+ programs –WHAT LEARNING IS THERE FROM B+ ON HOW THIS CAN WORK IN PRACTICE?

Programmes should provide community support for people living with HIV to improve retention in HIV care. Interventions:  Multi-faceted, community-based lay CHWs/ “patient advocates” providing adherence, treatment and psychosocial support.  Adherence clubs and peer groups providing patient support: postpartum and breastfeeding women, children, key population, adolescents, men. The importance of community support is highlighted in new recommendations for retention

As a result of B+, maternal coverage in the 21 Global Plan countries now exceeds adults & children Percentage of pregnant women, adults and children (0-14 years) receiving ART in the 21 Global Plan priority countries from Source: Courtesy of Karusa Kiragu, UNAIDS

2015 WHO ARV Consolidated Guidelines

Acknowledgements Core Group Co-Chairs Wafaa El-Sadr (ICAP and Columbia University) Yogan Pillay (SA MoH) SD Guideline Development Group Co-Chairs Anthony Harries (the Union) Fabio Mesquita (Brazil MOH) Members of service delivery GDG Special thanks to all the external experts who contributed as members of the Guideline Development Groups, and to those who contributed to the GRADE systematic reviews and supporting evidence which informed the guidelines process. WHO Department Meg Doherty Andrew Ball Rachel Baggaley Rachel Beanland Marco Vitoria Martina Penazzato Shaffiq Essajee Nathan Ford Eyerusalem Kebede Negussie Joseph Perriëns Francoise Renaud Bob Grant (consultant) Annabel Baddaley Haileyesus Getahun Other Contributors The University of California, San Francisco & University of Basel Global Evaluation Service (GES) The HIV Modelling Consortium JHU Pangaea APN+, AHF, ITPC, EATG, AFROCAB, IeDEA Collaboration The Global Network of People living with HIV/AIDS Avenir Health CDC PEPFAR Bill and Melinda Gates Foundation UNICEF, UNAIDS, GF