Treatment as Prevention and Treatment 2.0 Update UN Forum on AIDS, 24 June 2011 Nicole Seguy, Zhang Lan, WHO

What is TASP? Use of ART among HIV-infected individuals to decrease HIV transmission at the population level in order to stop the HIV epidemic TASP perspectives: –benefit for the community –benefit versus risk of starting ART earlier for HIV-infected individuals

What do we know, so far? Mathematical modeling has demonstrated the potential of earlier start of ART for all HIV+ to stop the HIV epidemic

What do we know so far ? Viral load is the strongest risk factor for transmission ART can lower VL to undetectable levels PMTCT offers proof of concept of reduced transmission with ART Discordant couple studies are supportive Discordant couple observational studies Rakai cohort study, Uganda (Reynolds S et al. AIDS Feb 2011) ART provided at CD4< 250 Incidence not on ART: 8.6/100 py Incidence on ART: 0/25 py Rwanda and Zambia (Sullivan P, CROI 2009) Incidence not on ART: 3.4/100 py Incidence on ART: 0.7/100 py

What do we know, so far? Individual benefit of starting ART earlier (CD4>350) NA-ACCORD observational study: –higher risk of death (mostly related to non-AIDS events) when ART was started at CD4 350 but CASCADE cohort study in Europe has shown little survival benefits of earlier start

More on-going Studies

HPTN 052 Breakthrough 12 May 2011 results: “if an HIV-infected person adheres to an effective ART regimen, the risk of transmitting the virus to their uninfected sexual partner can be reduced by 96%”

WHO/ UNAIDS New Recommendations Michel Sidibe, May 2011: “Now we need to make sure that couples have the option to choose Treatment for Prevention and have access to it” In July 2011, WHO will release a recommendation and guidance on ART for discordant couples –ART for HIV+ in discordant couple irrespective of CD4 count –ART once started should be continued for life –No single method is fully protective –couples should make evidence-informed decisions on which combination of HIV prevention options is best for them

Remaining Challenges and Obstacles

Awareness of HIV Status and Treatment in China, 2010 中国 HIV 感染知晓率与治疗比例， 2010 December 7, 2015© 2010 Bill & Melinda Gates Foundation | % Knew their status Source: Ray Yip, Gates Foundation

How to Address these Challenges and reach Universal Access to ART by 2015? Treatment 2.0

Treatment 2.0 Priorities TREATMENT 2.0 Adapt delivery systems Mobilize communities POC and other simplified monitoring Optimize drug regimens Reduce costs

point of care diagnostics in China Progress in point of care diagnostics in China Use of rapid HIV test: –New Technical Manual for HIV Rapid Testing –Possibly use of RT by non health staff –Provision of preliminary results ->Pre-qualification of RT (WHO ) ->Quality assurance / QC systems (US CDC) ->Post market surveillance (WHO) Integration of syphilis and HIV RT screening for ANC and possibly MSM –MSM RT training (14-15 June 2011) –MSM guidelines (14 June) ->NCSTD rapid syphilis pilot screening in outreach SW and MSM services at 2 sites

Progress in Adapting Delivery Systems in China Expand HIV testing and counselling (PITC and community-based) Strengthen procurement and supply systems: WHO/MSH assessment and SOP Continuous Quality Improvement system pilot in 4 provinces Costing of community based service delivery (AIDS Care China) Strengthened collaboration between health staff, local CDC and CBO at some sites (T2.0 pilots) Draft M&E framework for HTC to treatment cascade at T2.0 pilots

Progress in Mobilizing Communities in China  Strengthen demand side for treatment  Community-based testing and counselling  Involvement in design and delivery of treatment programs  Design and delivery of care and support services

Progress in Optimizing Drug Regimens in China Revised National Free ART manual using WHO 2010 recommendations: –TDF based regimens for patients co-infected with hepatitis B as a first step –D4T phase out plan Revised National PMTCT Guidelines using 2010 WHO recommendations: –Triple maternal ARV prophylaxis

Progress and Challenges in reducing Treatment Costs in China Services delivery costs: –wider CBO engagement in service delivery to improve adherence and delay second line (T2.0 pilots: cost saving estimations) ARV costs: –Current high ARV drug prices in China –Scenario-based cost reduction analysis for ARV drugs (CHAI, Dec. 2010) –Possibilities to purchase or produce cheaper drugs (including generic FDC) should be used –China should be able to offer TDF based first line regimen to all patients

Thank You