From 3by5 to Universal Access – lessons learned and new challenges ODI Meetings Series Do big plans help big numbers? 7 th June 2006 Prof Charlie Gilks Director, Treatment and Prevention Scale-up Department of HIV/AIDS WHO, Geneva

2 The start: taking treatment seriously Big numbers – 6 million+ in need of ART Almost none (outside Brazil) accessing it The treatment gap declared a global health emergency Sept 22, 2003 UN General Assembly, New York "3 by 5" launched December 1 st 2003

3

4 3 by 5 target and goal The target is three million people on treatment by the end of 2005 The goal is universal access to anti- retroviral therapy as a human right

5

6 A public health approach to ART The goal is to maximise survival at the population level Provider-initiated testing and counselling Routine offer of HIV test when treatment available ART is standardised and simplified 3 classes of ARVs which are orally available Two distinct, independent and potent treatment combinations: first line: NNRTI + 2 NRTIs second line: bPI + 2 NRTIs (new/not yet used) Care is standardised and simplified Clinical decision making and management: the 4 S's of ART Management of toxicity and drug-drug interactions Patient tracking and programme M&E Surveillance and monitoring ARV drug resistance Population-based rather than individualised

7 TDF* or ABC AZT* or d4T NVP EFV 3TC or FTC Triple NRTI alternative approach # Preferential NRTI/NNRTI approach # Triple NRTI should be considered as a simplification strategy for 1st line as suggested above, mainly for situations where NNRTIs options provide additional complications ( e.g., pregnancy, viral hepatitis co-infection, TB confection, women who wish to fall pregnant or who have CD4 > 250; NVP or EFV grade 4 SAE; HIV-2 or HIV-0; adolescents). * Preferential NRTI 1 st Line ARV Drugs in Adults and Adolescents

8 Trends in the cost of first-line regimens in low-income countries, overlaid with the number of people treated,

Two year survival with ART by baseline CD4 Proportion alive Entebbe Cohort DART trial 0-49 cells/mm cells/mm cells/mm cells/mm 3 Years from cohort entry

"3 by 5" progress December 2005

11 Antiretroviral therapy coverage in low- and middle-income countries, December 2005 Geographical RegionNumber of people receiving ARV therapyEstimated need Coverage (low estimate – high estimate) Sub-Saharan Africa ( – ) % Latin America and the Caribbean ( – ) % East, South and South-East Asia ( – ) % Europe and Central Asia ( – ) % North Africa and the Middle East4 000(3 000 – 5 000) % Total ( – )6.5 million20%

12 Number of people receiving ARV therapy in low and middle income countries,

13 Percentage of people in sub-Saharan Africa on antiretroviral therapy among those in need

14 Percentage of women among all adults receiving antiretroviral therapy, 2005

15 Scaling up of antiretroviral therapy in Malawi,

16 Beyond 3 by 5 … to Universal Access Communiqué of G8 Summit in Gleneagles 2005 "With the aim of an AIDS-free generation in Africa, significantly reducing HIV infections and 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"

17 Lessons learned from 3x5 … ART is finally an integral and core component of the national response to HIV/AIDS Prevention alone does not work well ART alone is unsustainable No false dichotomies … Prevention or ART Evidence-based standards for prevention care and ART Evidence poorly collated and synthesised Relevant data not always collected (esp. for public health approach) Coordinated responses mandated: the 3 ones Multiplicity of players Great number of responses

18 Lessons learned from 3x5 … Target-driven approach to public health works National NOT global: accountability and ownership Simple and tangible for political buy-in Prevention targets – but this is never "sexy" Simple commodities / formularies for treatment Procurement and supply management Market place for products First-line; now paediatric ART and second-line Tracking progress to show successes Donors to show effectiveness of spend Civil society to hold governments accountable Measurable targets

19 Challenges … Ensure prevention is not left behind Prevention better than "cure" Prevention not as appealing Prevention targets difficult Multisectoral and many partners Chronic disease management Beyond the numbers starting Quality of care for life Person-centred care in the community

20 Dr LEE Jong-wook