2017 IAS Conception Meeting 90-90-90 and Conception 2017 IAS Conception Meeting Paris, France July 25th, 2017 Last updated: May 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 Women and HIV HIV Policy work Global 90-90-90 status report Conclusions

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

HIV treatment reduces viral load and heterosexual transmission (2003) Viral load is the single greatest risk factor for HIV transmission. Quinn's landmark study in Rakai, Uganda showed that patients with less than 400 copies of HIV RNA per mililiter have the lowest rate of HIV transmission, followed by a stepwise increase in transmission rates for higher RNA levels. Quinn et al. NEJM. 2003;342(13):921-929.

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!

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

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

Reported and projected people on ART 32 mn (81%) 19.5 mn (53%) 27 mn (69%) 8 mn (23%) Numbers in bracket show ART coverage Currently putting 2 million people on ART each year. Expand treatment to 3 million people each year to achieve 90-90-90 by 2020.

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

ART initiation criteria ART initiation for asymptomatic people ART initiation criteria No. of Countries People with HIV (2016) Countries Irrespective of CD4 count 58 29,800,000 (81%) Argentina, Australia, Austria, Botswana, Brazil, Bulgaria, Burundi, Cambodia, Canada, China, Croatia, Democratic Republic of Congo, Denmark, Ethiopia, France, Georgia, Germany, Ghana, Haiti, India, Italy, Jamaica, Japan, Kenya, Korea (Republic), Lao PDR, Lesotho, Malawi, Malaysia, Maldives, Mexico, Montenegro, Mozambique, Namibia, Netherlands, New Zealand, Nigeria, Norway, Panama, Papua New Guinea, Poland, Portugal, Romania, Russia, Rwanda, South Africa, Spain, Sri Lanka, Swaziland, Sweden, Switzerland, Thailand, Turkey, Uganda, United Kingdom, US, Zambia, Zimbabwe Consider for >500 5 270,000 (0.7%) Colombia, Greece, Guyana, Hong Kong, Venezuela ≤500 32 4,400,000 (12%) Algeria, Angola, Bangladesh, Bhutan, Bolivia, Cameroon, Chile, Cote d’Ivoire, Ecuador, El Salvador, Fiji, Gabon, Honduras, Kazakhstan, Liberia, Madagascar, Mali, Mauritania, Moldova, Myanmar, Nepal, Oman, Pakistan, Peru, South Sudan, Sudan, Tanzania, Tunisia, Ukraine, Uruguay, Uzbekistan, Viet Nam ≤350 (consider for CD4 ≤ 500) 200,000 (0.6%) Belize, Costa Rica, Finland, Guinea, Philippines ≤350 19 1,100,000 (3%) Afghanistan, Benin, Burkina Faso, Djibouti, Dominican Republic, Guatemala, Indonesia, Latvia, Marshall Islands, Morocco, Nicaragua, Niger, Paraguay, Samoa, Sierra Leone, Tajikistan, Timor-Leste, Tuvalu, Vanuatu ≤300 1 350 (<0.1%) Macedonia ≤200 (consider for CD4 ≤ 350) 58,000 (0.2%) Belarus, Cape Verde, Cuba, Estonia, Hungary ≤200 2 41,000 (0.1%) Comoros, Senegal 19 countries in yellow have reported new recommendations. Percentage represents proportion of 36.6 million people living with HIV (97.8% burden) Source: published policy Guidelines from 127 countries

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

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

ART INITIATION CRITERIA ART initiation for pregnant women ART INITIATION CRITERIA NO. OF COUNTRIES COUNTRIES Option B+ 101 Algeria, Angola, Argentina, Australia, Austria, Bangladesh, Benin, Bhutan, Bolivia, Botswana, Brazil, Bulgaria, Burundi, Cambodia, Canada, Cameroon, Chile, China, Costa Rica, Cote d’Ivoire, Croatia, Democratic Republic of Congo, Denmark, Dominican Republic, Ecuador, El Salvador, Ethiopia, France, Fiji, Finland, Gabon, Germany, Georgia, Greece, Ghana, Guatemala, Haiti, Honduras, India, Indonesia, Italy, Jamaica, Japan, Kazakhstan, Kenya, Korea, Lao PDR, Lesotho, Liberia, Madagascar, Malawi, Malaysia, Maldives, Mali, Mauritania, Mexico, Moldova, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Nigeria, Norway, Pakistan, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Romania, Russia, Rwanda, Spain, Sri Lanka, South Africa, South Sudan, Sudan, Swaziland, Sweden, Switzerland, Uganda, UK, US, Uruguay, Venezuela, Tajikistan, Tanzania, Thailand, Tunisia, Turkey, Ukraine, Viet Nam, Zambia, Zimbabwe ≤500 4 Colombia, Hong Kong (China), Oman, Uzbekistan ≤350 14 Afghanistan, Belize, Burkina Faso, Djibouti, Guinea, Guyana, Latvia, Marshall Islands, Niger, Samoa, Sierra Leone, Timor-Leste, Tuvalu, Vanuatu ≤300 1 Macedonia ≤200 (consider for ≤350) Belarus, Cape Verde, Estonia, Hungary ≤200 3 Comoros, Cuba, Senegal Source: published policy

Irrespective of CD4 count Policy Lag in LMICs (85 countries) WHO 2009 guidelines WHO 2013 guidelines WHO 2015 guidelines Date of publication October, 2009 June, 2013 September, 2015 ART eligibility criteria <350 cells/mm3 <500 cells/mm3 Irrespective of CD4 count Average time to adopt the WHO guidelines 25 [3-68] months (n = 50) 15 [0-43] months (n = 59) 12 [1-20] months (n = 31) Countries yet to adopt the recommendation 17 (3% burden) 47 (15% burden) Data as of July, 2017

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

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%) Botswana, civ, ethiopia, haiti, PNG, Vietnam, Canada, Lesotho, Uganda 85 (77% global HIV burden in 2016) with complete care continua

Mapping on ART and viral suppression 90-90-90 targets (85 countries) Green – achieved; yellow – on track; red; off track There were no outliers i.e. a country that had high ART coverage but low suppression or visa versa ART coverage >81% and viral suppression >73% ART coverage 60-80% and viral suppression 50-72% ART coverage <60% and viral suppression <50% Incomplete or no continua 85 countries with complete care continua

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

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

Documenting and grading continua methods

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

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

Age category cascades allow for improved focus

ART coverage among adolescents and young adults (15-24 years) in 10 countries 71% 77% 84% 32% 34% 40% 64% 61% 68% 70% 90-90-90 target: 81% 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.

Viral suppression among adolescents and young adults (15-24 years) in 8 countries 79% 63% 51% 59% 61% 25% 29% 90-90-90 target: 73% 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.

HIV, TB and HIV/TB: New cascade

Phases of HIV Epidemic 1980-2020 1985 1990 1995 2000 2005 2010 2015 2020 Phases of HIV Epidemic 1980-2020 Devastation Discovery End of AIDS 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 WHO 3x5 2005 1st generic ARVs 2005 Circumcision RCTs 2006 TasP proposed as HIV control strategy 2008 Swiss statement 2009 Attia metaanalysis 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 UNAIDS 90-90-90 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 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 2005 40.3M PLHIV 2M (5%) Tx 2015 36M PLHIV 16M (44%) Tx Policy Hit early, hit hard. Almost no access to treatment in low and middle income countries 2003 WHO CD4 <200 2009 WHO CD4 <350 2012 US Treat All 2013 WHOCD4 <500 2015 WHO Irrespective CD4 Granich Lancet 2017

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

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

Leadership matters

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

Proportion of HIV spending on care and treatment, HIV spending on care and treatment per PLHIV Data for 38 countries with highest HIV burden in 2013 (73% global burden).