Update on global progress in ART outcomes Silvia Bertagnolio HIV Department WHO, Geneva

Significant progress towards ending AIDS Although significant progress has been made towards ending AIDS as a public health threat, 78%, 86% WHO/UNAIDS July 2019

Many gaps in service access and quality remain An ambitious treatment target to help end the AIDS epidemic By 2020 90-90-90 90% of people living with HIV are virologically suppressed 90% of people living with HIV are receiving ART 90% of people living with HIV are diagnosed Although significant progress has been made towards ending AIDS as a public health threat, 78%, 86% 79% 62% 53% WHO/UNAIDS July 2019

Quality health service delivery To reach global targets, HIV programmes must establish and maintain systems for ensuring a high level of quality in service delivery This, within the framework of universal health coverage and supported by national quality policies and strategies What are?

NNRTI pretreatment HIV drug resistance (national surveys) 5 in Africa: SA, Uganda, Namibia, Zimbabwe, Eswatini; 5 in Central/South America: Argentina, Honduras, Cuba, Nicaragua, Guatemala; 2 in South East Asia: Nepal, PNG. shows point prevalence of PDR to EFV/NVP and 95% confidence intervals among the 18 countries reporting data to WHO between 2014-2018; NNRTI PDR prevalence in populations initiating ART had exceeded 10% (vertical dotted line) in 12 countries with red dot distributed as follows: 5 in Africa: SA, Uganda, Namibia, Zimbabwe, Eswatini; 5 in South America: Argentina, Honduras, Cuba, Nicaragua, Guatemala; and 2 in South East Asia: Nepal, PNG. The dotted line at 10% indicate the NNRTI PDR prevalence above which WHO recommends moving away from NNRTIs in first-line ART. PDR estimates were generated from nationally representative surveys using WHO methods except in SA where data are generated from a national household survey. In 14 countries people starting ART regardless of prior ARV exposure were enrolled; in 4 countries (Brazil, Colombia, Cuba, Zimbabwe) the protocol was adapted and only people starting ART who are ARV drug naive are included. 2012 WHO HIVDR Report

IMPACT OF HIV DRUG RESISTANCE (mathematical model) Cost of No Action IMPACT OF HIV DRUG RESISTANCE (mathematical model) Projected impact in sub-Saharan Africa if NNRTI PDR >10% and NNRTIs continue to be used in first-line Phillips, et al. JID, 2017

HIVDR can be minimized by closing gaps in quality of HIV treatment service delivery HIVDR is a consequence of suboptimal quality of care. To preserve the long term durability of DTG, improving the quality of care and quality monitoring is critical

Quality of care indicators associated with HIVDR TARGET 1 RETENTION on ART at 12 MONTHS >85 % 75-85% <75% 2 ON TIME PILL PICK-UP >90% 80-90% <80% 3 DRUG STOCK OUT 0% >0% 4 VIRAL LOAD SUPPRESSION at 12 MONTHS 5 VIRAL LOAD TESTING COVERAGE >70% <70% 6 APPROPRIATE SWITCH TO SECOND-LINE ART 100% <100% WHO, Patient-centred monitoring guidelines, 2017; WHO Consolidated SI guidelines, 2015.

Quality of care indicators associated with HIVDR emergence (2015-2017) Retention 12 months after ART initiation.   The proportion of countries with classifiable data was 18/45 (40%) in 2017, The proportion of reporting countries meeting the target (≥85%) was 28% in 2017 (6/18). Viral load testing coverage.  The proportion of countries with data was 29/45 (64%) in 2017. The proportion of reporting countries achieving the target of ≥70% was 31% (8/29) in 2017. Viral load suppression. The proportion of countries with classifiable data was 15/45 (33%) in 2017, respectively. Among these countries 20% (3/15) met the target in 2017. Drug stock-outs. The proportion of countries reporting was 30/45 (67%) in 2017. The proportion of reporting countries meeting the target of zero drug stock-outs was 53% in 2017 (16/30). Proportion of patients on second-line ART. The proportion of people switched to second-line is a proxy measure of how well a country uses viral load results to identify failures and switch them timely so that emergence and accumulation of HIVDR is prevented. Programmatic and survey data show that about 10-20% of people receiving ART, have viral non-suppression and may thus need to switch to second-line ART. The proportion of reporting countries was (64%) in 2017. The proportion of reporting countries that met the target of having at least 5% of patients on a second-line regimen was 45% (13/29) in 2017. aSource: UNAIDSInfo, UNAIDS/WHO Global AIDS Monitoring tool and WHO/AIDS Medicines and Diagnostics Survey on the use of ARV medicines and laboratory technologies and implementation of WHO related Guidelines. c Countries’ datasets were included if comprise ≥70% of people newly initiated on ART; or <70% but reported to be nationally representative e Countries’ datasets were included if viral load testing coverage was ≥70%; or <70% and reported to be nationally representative.

Countries meeting target of the quality of care indicators associated with HIVDR (2016-2018) VL testing coverage increased VL suppression stable Year # countries reporting VL testing coverage # countries reporting VL suppression (and with VL testing coverage >70%) 2016 18 8 2017 29 15 2018 40 16

Countries meeting target for the quality of care indicators associated with HIVDR (2016-2018)...cont Retention down Stock out stable Second line use reduced Year # countries reporting national representative retention data # countries reporting stock out data # countries reporting number of people on second-line ART 2016 15 32 16 2017 18 30 29 2018 21

Proportion of clinics achieving targets of retention on ART at 12 months in 10 countries All 9 countries reported data on 12-month retention on ART among patients newly initiated on ART. In most of the countries (8/10), <60% of the clinics met the target of ≥85% retention and ranged from a low of 2% in Ghana to 100% in Benin. (Fig 4.2)

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Quality improvement approach A model: the plan-do-study-act cycle Quality improvement is a systematic approach to improve quality by: DO: measuring indicators identying quality gaps A model: the plan-do-study-act cycle STUDY: exploring their root causes designing & implementing contextually appropriate solutions, informed and supported by the community ACT: implementing interventions assessing their impact

Conclusions Few countries reported nationally representative data, requiring strengthening of record keeping system. Important quality gaps in ART service delivery identified: suboptimal retention; drug stock outs; VL testing coverage and suppression; suboptimal use of second-line ART. Monitoring quality of care indicators identifies weaknesses at ART clinic- and programme level associated with population-level emergence of HIVDR and represents our first-line of defence in preventing HIVDR. Monitoring indicators in isolation, however, is not sufficient, and should be part of a robust national quality strategy and quality improvement approach so that quality gaps are identified and corrective actions triggered. Heightened vigilance and rapid response to clinic and programme situations favoring HIVDR is urgently required to maximize the quality of ART services and preserve the durability and efficacy of DTG now and in the future. Common themes