1. 2017 IAS Conception Meeting
and Conception
2017 IAS Conception Meeting
Paris, France
July 25th, 2017
Last updated: May 2017
Reuben Granich, MD, MPH
Somya Gupta MA
International Association of
Providers of AIDS Care (IAPAC)

2. Disclosures No Gilead Funding No Gates Foundation Funding
No Research Trial funding

3. Outline Women and HIV HIV Policy work Global 90-90-90 status report
Conclusions

4. Treatment matters CD4+ cell count Mortality at one year HIV-positive
HIV+ and HIV- post-partum women in Harare ( )
2.5x
3.9x
100x
HIV-negative
Data: Hargrove AIDS 2010; Model: Williams JID 2006.

5. HIV treatment reduces viral load and heterosexual transmission (2003)
Viral load is the single greatest risk factor for HIV transmission. Quinn's landmark study in Rakai, Uganda showed that patients with less than 400 copies of HIV RNA per mililiter have the lowest rate of HIV transmission, followed by a stepwise increase in transmission rates for higher RNA levels.
Quinn et al. NEJM. 2003;342(13):

6. Apollo 13 strategy: “Working the Ending AIDS problem”
Set clear and shared goals
Change business as usual
Establish accountability and use open data
Accelerate pace of science to service delivery
Budget for success
Leadership on goals, priorities, execution and accountability
Failure is not an option!

7. Global HIV Status Report (2015/16)
Half empty:
1.8 million infections per
year
37 million PLHIV
1 million HIV deaths
1.2 million HIV/TB illnesses
400,000 HIV/TB deaths
Half full:
19.5 million on ART (50%)
~70% of PLHIV know status
19 billion USD per year
TB among PLHIV down
32% from 2005
Half full, half empty?.... it’s still half!
Source: UNAIDS Fact Sheet.

8. Global access to HIV treatment, 2010-2016
81%
Treatment gap
On ART

9. Reported and projected people on ART
32 mn
(81%)
19.5 mn
(53%)
27 mn
(69%)
8 mn
(23%)
Numbers in bracket show ART coverage
Currently putting 2 million people on ART each year. Expand treatment to 3 million people each year to achieve by 2020.

10. Answer: One policy for polio eradication using tOPV
Can anyone tell me what policy this
WHO map is showing?
Answer: One policy for polio eradication using tOPV
Source: MMWR July 3, 2015

11. ART initiation criteria
ART initiation for asymptomatic people
ART initiation criteria
No. of Countries
People with HIV (2016)
Countries
Irrespective of CD4 count 58
29,800,000 (81%)
Argentina, Australia, Austria, Botswana, Brazil, Bulgaria, Burundi, Cambodia, Canada, China, Croatia, Democratic Republic of Congo, Denmark, Ethiopia, France, Georgia, Germany, Ghana, Haiti, India, Italy, Jamaica, Japan, Kenya, Korea (Republic), Lao PDR, Lesotho, Malawi, Malaysia, Maldives, Mexico, Montenegro, Mozambique, Namibia, Netherlands, New Zealand, Nigeria, Norway, Panama, Papua New Guinea, Poland, Portugal, Romania, Russia, Rwanda, South Africa, Spain, Sri Lanka, Swaziland, Sweden, Switzerland, Thailand, Turkey, Uganda, United Kingdom, US, Zambia, Zimbabwe
Consider for >500 5
270,000 (0.7%)
Colombia, Greece, Guyana, Hong Kong, Venezuela
≤500 32
4,400,000 (12%)
Algeria, Angola, Bangladesh, Bhutan, Bolivia, Cameroon, Chile, Cote d’Ivoire, Ecuador, El Salvador, Fiji, Gabon, Honduras, Kazakhstan, Liberia, Madagascar, Mali, Mauritania, Moldova, Myanmar, Nepal, Oman, Pakistan, Peru, South Sudan, Sudan, Tanzania, Tunisia, Ukraine, Uruguay, Uzbekistan, Viet Nam
≤350 (consider for CD4 ≤ 500)
200,000 (0.6%)
Belize, Costa Rica, Finland, Guinea, Philippines
≤350 19
1,100,000
(3%)
Afghanistan, Benin, Burkina Faso, Djibouti, Dominican Republic, Guatemala, Indonesia, Latvia, Marshall Islands, Morocco, Nicaragua, Niger, Paraguay, Samoa, Sierra Leone, Tajikistan, Timor-Leste, Tuvalu, Vanuatu
≤300 1
350 (<0.1%)
Macedonia
≤200 (consider for CD4 ≤ 350)
58,000
(0.2%)
Belarus, Cape Verde, Cuba, Estonia, Hungary
≤200 2
41,000 (0.1%)
Comoros, Senegal
19 countries in yellow have reported new recommendations.
Percentage represents proportion of 36.6 million people living with HIV (97.8% burden)
Source: published policy
Guidelines from 127 countries

12. ART initiation for asymptomatic people
2015 WHO Recommendation : Irrespective of CD4 count
<200, <250 or <300
<350
<500
>500
Irrespective of CD4 count
58 countries or 81% of burden
Source: published policy July 2017

13. ART initiation criteria in Africa
2015 WHO Recommendation : Irrespective of CD4 count
<200
<350
<500
Irrespective of CD4 count
Source: published policy July 2017

14. ART INITIATION CRITERIA
ART initiation for pregnant women
ART INITIATION CRITERIA
NO. OF COUNTRIES
COUNTRIES
Option B+
101
Algeria, Angola, Argentina, Australia, Austria, Bangladesh, Benin, Bhutan, Bolivia, Botswana, Brazil, Bulgaria, Burundi, Cambodia, Canada, Cameroon, Chile, China, Costa Rica, Cote d’Ivoire, Croatia, Democratic Republic of Congo, Denmark, Dominican Republic, Ecuador, El Salvador, Ethiopia, France, Fiji, Finland, Gabon, Germany, Georgia, Greece, Ghana, Guatemala, Haiti, Honduras, India, Indonesia, Italy, Jamaica, Japan, Kazakhstan, Kenya, Korea, Lao PDR, Lesotho, Liberia, Madagascar, Malawi, Malaysia, Maldives, Mali, Mauritania, Mexico, Moldova, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Nigeria, Norway, Pakistan, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Romania, Russia, Rwanda, Spain, Sri Lanka, South Africa, South Sudan, Sudan, Swaziland, Sweden, Switzerland, Uganda, UK, US, Uruguay, Venezuela, Tajikistan, Tanzania, Thailand, Tunisia, Turkey, Ukraine, Viet Nam, Zambia, Zimbabwe
≤500 4
Colombia, Hong Kong (China), Oman, Uzbekistan
≤350 14
Afghanistan, Belize, Burkina Faso, Djibouti, Guinea, Guyana, Latvia, Marshall Islands, Niger, Samoa, Sierra Leone, Timor-Leste, Tuvalu, Vanuatu
≤300 1
Macedonia
≤200 (consider for ≤350)
Belarus, Cape Verde, Estonia, Hungary
≤200 3
Comoros, Cuba, Senegal
Source: published policy

15. Irrespective of CD4 count
Policy Lag in LMICs (85 countries)
WHO 2009 guidelines
WHO 2013 guidelines
WHO 2015 guidelines
Date of publication
October, 2009
June, 2013
September, 2015
ART eligibility criteria
<350 cells/mm3
<500 cells/mm3
Irrespective of CD4 count
Average time to adopt the WHO guidelines
25 [3-68] months
(n = 50)
15 [0-43] months
(n = 59)
12 [1-20] months
(n = 31)
Countries yet to adopt the recommendation 17
(3% burden) 47
(15% burden)
Data as of July, 2017

16. 90-90-90 and Continuum of Care Targets
90%
90%
90%
Know status
On treatment
Virally suppressed
90%
81%
73%

17. People living with HIV diagnosed positive (2010-2017) UNAIDS target 90%
90%-100%
70-89%
Below 70%
Data not available
Incomplete or no
continua
People living with HIV diagnosed positive (Target 90%)
Botswana, civ, ethiopia, haiti, PNG, Vietnam, Canada,
Lesotho,
Uganda
85 (77% global HIV burden in 2016) with complete care continua

18. Mapping on ART and viral suppression 90-90-90 targets (85 countries)
Green – achieved; yellow – on track; red; off track
There were no outliers i.e. a country that had high ART coverage but low suppression or visa versa
ART coverage >81% and viral suppression >73%
ART coverage 60-80% and viral suppression 50-72%
ART coverage <60% and viral suppression <50%
Incomplete or no continua
85 countries with complete care continua

19. Proportion of people living with HIV diagnosed and on ART
TARGET
UNAIDS target: 81%
UNAIDS target: 90%
87 countries with data on 1st and 2nd 90

20. Proportion of people living with HIV on ART and with viral suppression
TARGET
UNAIDS target: 73%
UNAIDS target: 81%
85 countries with complete care continua

21. Documenting and grading continua methods

22. Next generation cascades...
Key populations (MSM, FSW, PWID)
HIV and TB
Pediatric
Sub-national
Fast Track Cities
Age categories
Pregnant women and children

23. MSM living with HIV virally suppressed (Target: 73%)
73%-100%
50-72%
Below 50%
Data not available

24. Age category cascades allow for improved focus

25. ART coverage among adolescents and young adults (15-24 years) in 10 countries
71%
77%
84%
32%
34%
40%
64%
61%
68%
70%
target: 81%
Blue bars show ART coverage among adolescents and young adults ( data) while red lines show national ART coverage among all PLHIV. UNAIDS target for 2020 is 81% ART coverage.

26. Viral suppression among adolescents and young adults (15-24 years) in 8 countries
79%
63%
51%
59%
61%
25%
29%
target: 73%
Blue bars show viral suppression among adolescents and young adults ( data) while red lines show viral suppression among all PLHIV. UNAIDS target for 2020 is 73% viral suppression. Data unavailable for Cameroon and Ethiopia.

27. HIV, TB and HIV/TB: New cascade

28. Phases of HIV Epidemic 1980-2020
1985
1990
1995
2000
2005
2010
2015
2020
Phases of HIV Epidemic
Devastation
Discovery
End of AIDS
1981 AIDS
1983 HIV
1983 WHO surveillance
1983 Denver Principles
1985 HIV test
1987 AZT
1987 WHO GPA
1987 TASO
Uganda
1985 Reagan
mentions AIDS
1986 AIDS Quilt
1986 ACT-UP
1992 AIDS #1 killer US men years old
1993 US Office of National AIDS Policy
1994 AZT to prevent MTCT
1995 Protease inhibitor
1996 Vancouver triple therapy
1996 US home HIV test
1997 AIDS deaths decline 40% in US
1998 TAC South Africa
2001
Special UN Session “global emergency”
2002 Leading cause of death
2002
Global Fund established
2003
PEPFAR
WHO 3x5
2005 1st generic ARVs
2005 Circumcision RCTs
2006 TasP proposed as HIV control strategy
2008 Swiss statement
2009 Attia metaanalysis ART prevents transmission
2009 WHO proposes using treatment to eliminate HIV
2011
HPTN 052 proves ART blocks transmission
2012 PrEP approved in US
2010 UNAIDS Treatment 2.0 with treatment as prevention
2014 UNAIDS targets
2015 Fast Track Cities with 60+ cities
2015 STAR and TEMPRANO
2015 HealthGap access to treatment is human right
M (49%)people on treatment
2016 Cumulative 39 million AIDS deaths
2020
reached
targets affirmed
2020
37M PLHIV
27 (81%) Tx
1980
100,000 PLHIV
No treatment (Tx)
1985
Nearly million PLHIV
No treatment
1990
Millions PLHIV
No treatment
1995
20M PLHIV
No Tx
2000
34.3M PLHIV
1M (3%) Tx
Africa
50,000 (2%)
2010
33.3M PLHIV
7.5M (23%) treatment
2005
40.3M PLHIV
2M (5%) Tx
2015
36M PLHIV
16M (44%) Tx
Policy
Hit early, hit hard. Almost no access to
treatment in low and middle income countries
2003 WHO
CD4 <200
2009 WHO
CD4 <350
2012 US Treat All
2013 WHOCD4 <500
2015 WHO
Irrespective CD4
Granich Lancet 2017

29. Ending AIDS as a major public health problem
Feasible:
“capable of being done or carried out”
--Merriam-Webster’s Dictionary

30. Thank you HIV 90-90-90 watch HIV Policy Watch www.HIV90-90-90watch.org

31. Leadership matters

32. You get what you pay for..... Spending on ART 75% Number of countries
3/4 of the countries spend less than 26% of HIV budget on ART  
Proportion of HIV budget
Williams, unpublished data, UNAIDS GARPR database 2014

33. Proportion of HIV spending on care and treatment, HIV spending on care and treatment per PLHIV
Data for 38 countries with highest HIV burden in 2013 (73% global burden).