Excellent healthcare – locally delivered Strengthening the treatment cascade Evidence and practice Dr Nathan Ford Treatment and Care Department of HIV

Too few take a test Staveteig et al, DHS Comparative Reports, 2013 Global Update on HIV treatment, WHO, % - 69% 13% - 76% 37% Adults Pregnant women

Substantial attrition between testing and ART initiation Mugglin et al, Trop Med Int Health % lost at each step

Still too many people start ART late The IeDEA and ART cohort collaborations 1 in 4 start ART at CD4<100

Cumulative attrition on ART Global Update on HIV treatment, WHO, % LTF at 3 years

Improving testing and linkage Suthar et al, Plos Med 2013 [Accepted] Global Update on HIV treatment, WHO, 2013 Partner and couples testing Community testing Self-testing Combination testing DBS for early infant diagnosis Partner and couples testing Community testing Self-testing Combination testing DBS for early infant diagnosis

Enrollment in pre-ART care Wynberg et al, 2013 (submitted) Kohler et al, AIDS 2011 Enrollment in pre-ART care Earlier initiation PoC CD4 CTX Adherence clubs Earlier initiation PoC CD4 CTX Adherence clubs Wynberg et al, 2013 (submitted) Kohler et al, AIDS 2011 CTX prophylaxis PoC CD4 Adherence clubs

ART initiation Task shifting Decentralization Service integration Task shifting Decentralization Service integration TB/HIV integration India Paediatric decentralization in Thailand PMTCT B+ in Malawi Global Update on HIV treatment, WHO, 2013 Kredo et al, Cochrane Database of systematic reviews, 2013.

Adherence support FDCs Optimized regimens Viral load Adherence support (sms, clubs…) FDCs Optimized regimens Viral load Adherence support (sms, clubs…) Fixed-dose combinations Wilkinson, SAJHIV Med 2013; Ford et al, 2013 (submitted); Butler et al, IAS 2013

Summary Successful scale up of ART poses continued challenges to current models of care Evidence from research and programmes indicate ways to improve patient care at each step of the cascade Future research is needed to identify approaches to enroll people earlier onto ART and support long-term retention in care

WHO’s ongoing work to support ART delivery Support to regions for guideline rollout Future of ART monitoring Phasing out (d4T) and phasing in (viral load) Early Infant Diagnosis Paediatric treatment optimization Cotrimoxazole prophylaxis Implementation Science summit

Acknowledgements Gundo WeilerEric Goemaere Vincent HabiyambereMathias Egger Txema Garcia-CallejaAndrew Boulle Michel BeusenbergTrevor Peter Gottfried HirnschallLynne Wilkinson Meg DohertyHein Marais Cadi IrvineTony Harries Marco Vitoria Boniface Dongmo Nguimfack Eyerusalem Negussie Rachel Baggaley Nathan Shaffer