The 2013 Consolidated WHO Guidelines on ARV Use: Implementing to Achieve Maximum Impact Gottfried Hirnschall, MD, MPH Director, HIV/AIDS Department, WHO

Getting to Zero mortality 1.Taking stock: How close is Asia to zero HIV-related deaths? 2.Identifying current bottlenecks and response gaps 3.Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment 4.Looking ahead: current and future opportunities Getting to Zero mortality

1.Taking stock: How close is Asia to zero HIV-related deaths? 2.Identifying current bottlenecks and response gaps 3.Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment 4.Looking ahead: current and future opportunities Getting to Zero mortality

51% 64% Proportion of eligible adults living with HIV receiving ART, by region, 2009–2012 Adult ART coverage in Asia is below the global average for low- and middle-income countries Source: UNAIDS/WHO Coverage: number of adults receiving ART in 2012 / number of adults eligible for ART in 2012 according to 2010 guidelines.

ART coverage in selected Asian countries, 2012 Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines Great variability in access to ART in Asia Source: UNAIDS/WHO

30% 20% Peak: 2005 HIV-related deaths have decreased in Asia, but less than globally (in LMICs) Source: UNAIDS/WHO

1.Taking stock: How close is Asia to zero-AIDS related deaths? 2.Identifying current bottlenecks and response gaps 3.Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment 4.Looking ahead: vision and opportunities for the future Getting to Zero mortality

Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010 In Asia, 1 in 3 patients started ART at CD4<100* in 2010 Still too many people start ART late

Sources: Estimated number of people living with HIV: UNAIDS WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013 Cascade of HIV diagnosis to viral suppression, China, 2012 Too many people are not aware of their HIV status

Key populations: too many unaware of their HIV status Percentage of key populations who received an HIV test in the last 12 months and know their results % 52% 41% 33% Source: WHO, 2013

Too many people are lost to care after diagnosis Cascade of HIV diagnosis to care, Vietnam, 2012 Sources: Estimated number of people living with HIV: UNAIDS WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

Still too many people are lost from ART: Retention at 12, 24 and 60 months Still too many people are lost from ART: Retention at 12, 24 and 60 months % Source: WHO/UNAIDS

44 different first-line regimens 119 different second-line regimens 44 different first-line regimens 119 different second-line regimens 30% of patients still on d4T Only 18% of patients on TDF 30% of patients still on d4T Only 18% of patients on TDF Source: WHO ARV Use Survey, 2013 Are the optimal regimens being used? Proportion of d4T and TDF among adult patients on 1 st line ART by end of 2012 %

 Still too many people who: - do not know their HIV status - start ART late - take sub-optimal regimens - are lost to follow-up - do not have access to comprehensive package of care services Important challenges in Asia  Key populations require tailored approaches and service models

1.Taking stock: How close is Asia to zero-AIDS related deaths? 2.Identifying current bottlenecks and response gaps 3.Towards greater impact: The 2013 Consolidated ARVs Guidelines – earlier, better, and simpler treatment 4.Looking ahead: current and future opportunities Getting to Zero mortality

Threshold moved to < 500 CD4 (adolescents, adults, MSM, TG, SW, PWID) Priority for reaching all HIV+ symptomatic persons and those with CD4 < 350 CD4-independent situations for ART initiation: – HIV/TB coinfection and HBV advanced liver disease – HIV serodiscordant couples – Pregnancy: “options B/B+” – Children less than 5 years of age Earlier treatment initiation

Simpler and better treatment: one regimen for all Harmonize regimens : Adults, Pregnant Women (1 st trimester), Children >10 years, TB and Hepatitis B Simplicity: effective, well tolerated, once-daily FDC facilitates adherence Streamlines drug procurement and supply chain management Affordability: cost declined significantly since 2010 Harmonize regimens : Adults, Pregnant Women (1 st trimester), Children >10 years, TB and Hepatitis B Simplicity: effective, well tolerated, once-daily FDC facilitates adherence Streamlines drug procurement and supply chain management Affordability: cost declined significantly since 2010 Preferred 1 st line regimen: TDF + 3TC (or FTC) + EFV

Improved monitoring of ART Response  Key objective: earlier identification of treatment failure

Expanded HIV testing and counselling  Provider-Initiated Testing and Counselling (PITC)  Community-based testing (June 2013)  HIV Self testing (HIVST) FDA (USA) approval of OraQuick for HIVST (July 2012) Evolving approach, particularly relevant for key populations Legal, ethical, and public health implications

Countries are already moving: CD4 threshold for ART initiation * As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions Number of countries surveyed: 16 National policies as of August 2013 Likely changes

Countries are already moving: PMTCT – move to option B or B+ * As reported at Asia-Pacific PPTCT Task Force meeting, Kathmandu, Aug 2013; most countries convening policy reviews by end of 2014 to make decisions Number of countries surveyed: 16 National policies as of August 2013 Likely changes

Major reduction in mortality expected Estimated annual HIV-related deaths -39% Source: Special analysis conducted by Futures Institute, 2013

1.Taking stock: How close is Asia to zero-AIDS related deaths? 2.Identifying current bottlenecks and response gaps 3.Towards greater impact: The 2013 Consolidated ARVs Guidelines – better, earlier and simpler treatment 4.Looking ahead: current and future opportunities Getting to Zero mortality

The path towards “Zero deaths” Scale up InnovateResearch and develop Testing and ART to all people living with HIV Drugs Diagnostics Focus on key populations Linkages and retention Comprehensive care models Service delivery models Cure Preventive vaccine

The path towards “Zero deaths” Testing and ART to all people living with HIV Drugs Diagnostics Focus on key populations Linkages and retention Comprehensive care models Scale up Innovate Service delivery models Cure Preventive vaccine Research and develop

Scale up Innovate Research and develop The path towards “Zero deaths” Testing and ART to all people living with HIV Drugs Diagnostics Focus on key populations Linkages and retention Comprehensive care models Service delivery models Cure Preventive vaccine

Potential strategies to cure HIV Source: IAS

Conclusions: the way forward 1. Implement new ARV Guidelines: earlier, better, simpler ART 2.Focus on key populations: community-based models for testing; comprehensive care 3.Enhance service quality and integration for broader and sustained impact. 4.Lead Innovation and Increase Investments

Rachel Baggaley, Andrew Ball, Jhoney Barcarolo, Michel Beusenberg, Meg Doherty, Nathan Ford, Vincent Habiyambere, Ying-Ru Lo, Amaya Maw-Naing, Razia Pendse, Jos Perriens, Nathan Shaffer, Marco Vitoria, Gundo Weiler Acknowledgements