From "3 by 5" to Universal Access Kevin M. De Cock Director, HIV/AIDS Department

25 Years of AIDS 10 Years of HAART Epidemiologic Notes and Reports: Pneumocystis Pneumonia --- Los Angeles In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection. Case reports of these patients follow.

From "3 by 5" to Universal Access: outline Current status of HIV/AIDS treatment in the world Role of the health sector in working towards universal access Conclusions

Dr LEE Jong-Wook 1945-2006

Antiretroviral therapy coverage in low- and middle-income countries, June 2006 Geographical region Number of people receiving ARV therapy Estimated need Coverage Sub-Saharan Africa 1 040 000 4 600 000 23% Latin America and the Caribbean 345 000 460 000 75% East, South and South-East Asia 235 000 1 440 000 16% Europe and Central Asia 24 000 190 000 13% North Africa and the Middle East 4 000 75 000 5% Total 1 650 000 6 800 000 24%

20 low- and middle-income countries in sub-Saharan Africa, Asia, Latin America and the Caribbean treated more than 50% of those in need, June 2006

ARV Therapy: global need, June 2006 1 5 4 Sub-Saharan Africa Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East 3 2 (Number of people in millions) Unmet need Receiving ARV therapy 70% of the total unmet need

Women's access to HIV treatment, June 2006 United Republic of Tanzania Mozambique Malawi Zimbabwe Zambia Central African Republic Botswana Kenya Côte d'Ivoire Namibia Rwanda Burundi South Africa Uganda Nigeria 10% 40% 50% 60% 70% 20% 30% Percentage of adults on ART who are women Percentage of HIV-infected persons who are women

Children's access to HIV treatment, June 2006 Median: 8% Latin America Africa Median: 5 % Asia

Access to PMTCT services in sub-Saharan Africa, 2005 80 Percentage of HIV-infected pregnant women receiving ARV prophylaxis for PMTCT Togo Namibia 70 Zambia Guinea Bissau 60 Benin Central African Republic Swaziland 50 Burundi (Percentage coverage) Uganda 40 Gabon Rwanda 30 Kenya Zimbabwe 20 Lesotho Mozambique Côte d'Ivoire 10

Treatment access among IDU in Eastern Europe Serbia and Montenegro Czech Republic Moldova Estonia Ukraine 100 90 80 70 60 50 40 30 20 10 Lithuania Croatia Russian Federation IDU as % of people living with HIV IDU as % of people on ART Change this slide and put % of increase (in 2 slides animated) and show increase by country…

Equity of treatment access – knowledge gaps Coverage and quality of care in: Time Place Person

Estimated total annual resources available for AIDS, 1996–2005 Source: Lancet, 2006; 368: 526–30 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 World Bank MAP Launch Signing of Declaration of Commitment on HIV/AIDS Global Fund ( US$ millions ) PEPFAR

Prices of ARV therapy

Comparison of outcome in patients on ART in high- and low-income settings 18 programmes in Africa, Asia, South America (4,810 pts), 12 cohorts from Europe and North America (22,217 pts) Low-income patients: - More females (51% vs 25%) - Lower CD4+ (108 vs 234 per cu mm) - More NNRTI (70% vs 23%) Source: ART-Link and ART-CC Groups; Lancet, 2006

Comparison of mortality in the months after starting ART in low- and high-income settings 16 8 4 2 1 3 5 6 7 9 10 11 12 0.5 (Log scale of mortality rate %) (Months from starting HAART) Adjusted hazard ratios Source: ART-Link and ART-CC Groups; Lancet, 2006

CD4 TESTING NOT AVAILABLE WHO: public health approach to initiating ART CD4 TESTING AVAILABLE CD4 TESTING NOT AVAILABLE WHO CLINICAL STAGING Treat if CD4 count is below 200 cells/mm3 Do not treat 1 2 Consider treatment if CD4 count is below 350 cells/mm3 and initiate ART before CD4 count drops below 200 cells/mm3 Treat 3 Treat irrespective of CD4 cell count 4 Source: WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access Recommendations for a public health approach, 2006 revision

Mortality in patients on ART in low-income settings 73% deaths occurred in persons starting therapy at CD4+ <100 per cu mm 38% deaths occurred in first month, 80% in first 4 months Source: ART-LINC and ART-CC Groups, Lancet, 2006

User fees and treatment outcome 1. Meta-analysis of 10 studies by Ivers LC et al.: Free laboratory testing did not affect outcome Free treatment was associated with 29-31% increase in viral load suppression Source: Ivers LC et al., CID, 2005 2. ART-LINC: 75% lower mortality at 1 year with free treatment Source: ART-LINC, Lancet, 2006

Countries implementing WHO HIV ResNet Drug Resistance protocols Resistance map

Tuberculosis in patients on ART 1. Incidence Six countries: 3.0 – 17.6 per 100 py South Africa: 3.4 per 100 py (CD4+ <200) 1.7 per 100 py (CD4+ 200-350) 2. Recurrence Côte d’Ivoire: 11.0 per 100 py Sources: Badri et al., Lancet, 2002; Seyler et al., Am J Respir Crit Care Med, 2005; Bonnet et al., AIDS, 2006

Priorities to reduce mortality of HIV/AIDS patients in low-income settings Expand HIV testing for earlier diagnosis Ensure essential package of care for HIV-infected patients, including TB screening and co-trimoxazole Provide ART for Stages 3 and 4 disease as early as possible Expand CD4+ testing for earlier initiation of ART Abolish user fees

Universal Access 2005 G8 Summit at Gleneagles, Final Communiqué: “…working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010.”

The health sector's contribution to achieving Universal Access Expanding testing and counseling Accelerating treatment scale up Maximising prevention Strengthening health systems S T R A E G I C N F ORMA ON

AIDS cases, deaths and persons living with AIDS in the United States, 1985-2003 (CDC) 90 450 80 400 AIDS Cases 70 350 60 300 50 250 (AIDS cases and deaths in thousands) (Persons living with AIDS in thousands) 40 Deaths 200 30 150 20 100 10 50 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 Years

Health systems strengthening

WHO framework for monitoring the health sector: components of access Health interventions Availability: reachable and affordable ser- vices that meet a minimum standard Coverage: people using the intervention among those who need it Impact: reduction in new infection rates and improved survival of those infected

Testing and Counseling Family VCT Uganda Universal TC Lesotho Provider-initiated TC Kenya

Routine HIV testing in Botswana Routine testing in health care settings with right to decline was introduced in 2004 1 268 adults were interviewed 81-93% were in favour, said testing would be facilitated, treatment access enhanced 98% of persons tested expressed no regret Principal reasons for not testing: - fear (49%) - "no reason to believe infected" (43%) Source: Weiser SD et al, PLOS Medicine, 2006

Working towards universal access by 2010

Towards Universal Access