1. Excellent healthcare – locally delivered WHO Test & treat evidence and policy mapping What will it take to make the Test and Start guidelines a reality?' Meg Doherty, MD, MPH, PhD WHO Geneva Durban, 19 July 20167

2. 2 |2 | What’s new in the ARV Guidelines? Treat all - PLHIV of all ages and populations eligible to start at any CD4 cell count Using ARVs for Prevention – Pre-exposure prophylaxis (PrEP) to prevent HIV among people at significant risk of HIV Optimized ARV regimens – new ARV drug classes and better formulations Improved service delivery approaches - to reach all people at all ages Health systems strengthening– to avoid ARV stocks-out and risk the development of HIV drug resistance

3. 3 |3 | Movement to ‘Treat All’ happening Policy uptake for adults and adolescents, July 2016 24% of all LMIC and 40% of fast track countries have adopted Treat All By the end of 2016, more than half of all LMIC and 80% fast track countries will have adopted Treat All

4. 4 |4 | Policy uptake to full implementation, July 2016 Implementation is just getting underway and the majority of countries have not yet fully put the policy into practice for Treat All

5. 5 |5 | The success story of ‘treat all’ for pregnant women, July 2016

6. 6 |6 | Policy to Practice for Pregnant Women, July 2016

7. 7 |7 | Paediatric Treatment Policies, July 2016 – more variability 58% of LMIC and fast track countries will have adopted treat all for children.

8. 8 |8 | TDF/XTC/EFV adopted widely, July 2016 90% of LMIC adopted TDF + 3TC (or FTC) + EFV as the preferred first-line therapy

9. 9 |9 | Regional Variation in Policy Uptake, July 2016

10. 10 | Viral Load Challenges: policy into practice 10 Routine viral load is fully implemented in 47% of LMIC and partially implemented in 26% of LMIC.

11. 11 | Improved service delivery through differentiated models of care New recommendations for: Linkage to care with Rapid initiation of ART Adherence Retention “people-centered” integration with other services including STIs and NCDs New policies to improve programme efficiency: Less frequent clinic visits Less frequent medication pick-up visits for stable patients Trained lay providers can distribute ART in the community

12. Integrated service delivery HIV-Associated TB integration ART in MNCH care services Comprehensive services for people who inject drugs STIs and family planning services

13. Uptake of Service delivery recommendations, July 2016 % Children % Adults

14. Uptake of Co-infection recommendations, July 2016 % Children % Adults

15. Cumulative Incidence (%) of ART Initiation at the Original Clinic of Enrollment

16. Cumulative incidence of ART initiation at the original site of enrollment (CIF curves) August 2014 CD4<500 WHO III/IV Pregnant TB 2004-2010 CD4<200 WHO III/IV 2010-2014 CD4<350 WHO III/IV Pregnant TB August 2013 CD4<500 WHO III/IV Pregnant TB 2004-2007 CD4<200 2007-2009 CD4<350 WHO IV 2009-2013 CD4<350 WHO III/IV Pregnant (2011) TB BURUNDI RWANDA

17. 17 Threats to quality of system & EWI of HIVDR

18. 18 | Programme Managers Survey – what is needed to move Treat All Figure 1: Country HIV epidemic settings of survey respondents (N=41) Source: National ART Programme managers perspectives’ on implementing HIV interventions, KIT 2015 Figure 2: Top 3 requirements to enable your country to expand ARV treatment initiation criteria for each of the groups stated (N=33)

19. 19 | Threats and Responses to Treat All (Test and Start) Threats  Policy gaps  Leaky Cascade  Health Systems  Human resources  Supply Chain Management & Adequate stocks of goods  Financing for sustainability Responses/Opportunities  Evidenced informed interventions & differentiated service models  Differentiated models to support quality, person-centred care  Incorporate, train, mentor lay workers  Strengthen M&E, LMIS  Secure stocks ARVs; price reductions thru pooled procurement  Country level financing

20. What is WHO doing to support countries: Consolidated capacity building workshops Joint WHO Guidelines Dissemination Meetings (ARV, HTC, KP, SI) Locations / DateRegions Countries (108) Number people (639) Trinidad and Tobago March 2016 PAHO; NAP21120 Colombia April 2016 PAHO; NAP1552 S. Africa, May 2016 Anglophone AFR/EMR 16130 Cameroon, June 2016 Francophone AFR/EMR 1667 Mozambique, June 2016 Lusophone AFR570 Thailand, August 2016 SEAR/WPR/ EMR/Rwanda 23130 Belarus, September 2016 EUR1270+ Outcomes / Next Steps Adoption tools/documents Workshop Training Guide Policy briefs, fact sheets and Standard Slide sets in English, French, Portuguese (Russian, Spanish pending) Updated Policy adoption plans for all countries Library of online tools from partner Market Place wi, Nigeria, Mozambique, Angola, Botswana Direct Policy Adoption support: Nigeria guidelines meeting Rwanda Mid/term review and GL meeting Angola guidelines meeting Several VL scale up meetings (BKK, Swaziland, DRC) Kenya, Lesotho, S Africa, Malawi, Mozambique, Angola, Botswana

21. 21 | Acknowledgements  Olga Tymejczyk (CUNY, IeDEA CA)  Kathryn Anastos (Einstein, IeDEA CA)  Denis Nash (CUNY, IeDEA CA)  Théodore NIYONGABO (IeDEA CA, Burundi)  Christelle Twizere (IeDEA CA, Burundi)  Jean d’Amour SINAYOBYE (IeDEA CA, Rwanda)  Pacifique Mugenzi (IeDEA CA, Rwanda)  Benjamin Muhoza (IeDEA CA, Rwanda)  Athanase Munyaneza (IeDEA CA, Rwanda)  Rwanda Military Hospital (IeDEA CA, Rwanda)  NIH (1U01AI096299-01) IeDEA Central African Region (K Anastos and D Nash, MPIs)  Michel Beusenberg  Theresa Babovic  Florence Rusciano  Marco Vitoria  Nathan Ford  Martina Penazzato  Shaffiq Essajee

22. 1. DIAGNOSTICS ⇢ No out-of-pocket expenditures for TB tests ⇢ Rapid molecular test (i.e. Xpert) is initial diagnostic for all ⇢ Second-line drug susceptibility testing is available 2. MODELS OF CARE ⇢ Treatment initiation: TB at primary level, DRTB at district/below ⇢ Compulsory hospitalisation is not required ⇢ Immediate ART is offered to people living with HIV 3. DRUG REGULATION ⇢ NTP procures quality-assured TB drugs ⇢ Prescriptions are required for all TB drugs (not over-the-counter) ⇢ TB drugs benefit from accelerated registration 4. DS-TB TREATMENT ⇢ Daily fixed-dose combinations is standard of care ⇢ Treatment, including for children, reflect WHO guidance ⇢ TB contacts are screened, children & PLWHA receive IPT 5. DR-TB TREATMENT ⇢ DR-TB treatment reflects WHO guidance ⇢ WHO recommended DR-TB drugs are on national EML ⇢ New drugs are available via import waivers until full registration