1. Imperative of Test and Treat
Peter Mugyenyi
Joint Clinical Research Centre
Kampala, Uganda

2. Overwhelming evidence for Test and Treat

3. Abundant proof of Survival benefits of ART
0.95
0.94
0.55
0.92
0.90
0.18
164 events
LCM: 2.2/100 PY
1.0
0.90
0.87
0.08
CDM: 2.9/100 PY
218 events
0.8
0.6
Proportion alive
0.4
Entebbe Cohort:
pre-ART , median CD4 75 at enrolment:
57.7/100 PY
0.2
0.0 1 2 3 4 5
Years from enrolment
DART study results have demonstrated that ART services can be successfully implemented in rural areas
IAS July 2009

4. START Study HIV-infected individuals who are ART-naïve
CD4+ count > 500 cells/mm3
N = 4685
Immediate ART Group
N=2,326
Deferred ART Group
N=2,359
Primary composite endpoint, target = 213
Serious AIDS or death from AIDS
Serious Non-AIDS Events and death not attributable to AIDS
CVD, ESRD, decompensated liver disease, & non-AIDS defining cancers

5. Early versus deferred initiation of antiretroviral therapy in HIV-infection
CD4+ cell count
Primary endpoint:
SLIDE from A.Babiker
NEJM 2015

6. Number of subjects experiencing >1 event
HPTN 052 showed clinical benefit for earlier ART at <550 CD4 cell count
Number of subjects experiencing >1 event
Delayed
Immediate
Tuberculosis
34 (4%)
17 (2%)
Serious bacterial infection
13 (1%)
20 (2%)
WHO Stage 4 event
19 (2%)
9 (1%)
Oesophageal candidiasis 2
Cervical carcinoma
Cryptococcosis 1
HIV-related encephalopathy
Herpes simplex, chronic 8
Kaposi’s sarcoma
CNS Lymphoma
Pneumocystis pneumonia
Septicemia
HIV Wasting
Bacterial pneumonia
Source: Grinsztejn B, et al, Lancet Infectious Diseases, 4 March 2014

8. Simplified communication to the community
You don't take ART – you die You start late – you suffer (& may also die)

9. HIV treatment: The most effective biomedical intervention for the prevention of HIV transmission

10. Strategy to end AIDS epidemic: how are children doing?

11. The objective
“Maximize the effectiveness of existing tools to virtually eliminate progression to AIDS, premature death and HIV transmission by 2020, and thereby transform the HIV/AIDS pandemic into a low level sporadic endemic by 2030.”

12. Key challenges Lack of political will; Commitment of countries.
Finances: Increased support from PEPFAR, GF and donors as countries raise and commit more resources
Equity and human rights: Reach all in need without discrimination using safer and effective ART
Laboratory tests: Access to efficient and affordable laboratory technologies;

13. Political will Leadership and commitment: a demonstrable success;
Uganda leadership lead a prevention program
South Africa: Durban 2000 low ART – Now the worlds largest user
Botswana: Switched to the best available ART
Successes in Rwanda, Thailand, etc

14. 2005 G8 Summit at Gleneagles: promised universal Access
2005 G8 Summit at Gleneagles: promised universal Access.... “to all those who need it by 2010.”

15. Finances Country obligations:
Countries to fulfil their own commitments to increase health sector funding
Innovate other strategies for raising AIDS funds; e.g. Uganda tax levy on some luxuries, Zimbabwe, Kenya etc

16. Equity & Human rights Hard to reach?
a myth as politicians reach everywhere and everyone during election campaigns
Discrimination and stigma:
Laws that criminalise or discriminate against PLWHIV and others
Children HIV programs: lagging behind adults as per self explanatory data.

17. Disparities Between Adults And Children (% of ART Coverage Among Adults, Children in 22 Countries (2012)
Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting.
Note: Some numbers do not add up due to rounding. The coverage estimate is based on the estimated
unrounded number of children receiving and eligible for ART.

18. Access To Virologic HIV Testing (Early Infant Diagnosis) 2012
*Lesotho data represents 2011 coverage data Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting, and UNAIDS modeling2012 HIV and AIDS estimates.

19. Roles in effective partnership
Donors and international commitments
Reduce costly bureaucratic impediments
Involve recipient countries in planning
capacity building
Technology transfer
Long term strategies
Helping poor countries to get out of the poverty trap
TRIPS and Patents laws
International trade agreements
Justice and human rights
Affordable drugs
Ethical funding
Do no harm –make a difference
Long term commitment
Sustainability
Recipient countries and governments
Reduce wastage
Transparency and accountability
Cost cutting practices:
Task shifting,
multi-tasking
Exclude unnecessary tests
Integration of services
Best clinical practices to minimize resistance
Adherence
Reliable drugs logistics
Trained human resource
Good governance,
developmental policies,
human rights

20. Partnering for success
Advocacy/
Political
Normative/
Technical
Financing
R&D

21. Detractors or just misguided?
“We can’t treat our way through the epidemic”
– words of my co-presenter to the US congress 2010

22. Can we treat our way through the epidemic??
Yes, we must
The grim alternative is an epidemic without foreseeable end, with all the dire human, social and economic disastrous consequences.

23. acknowledgements DART research team
UNAIDS (Drs Michel Sedibe, Badara Samb et al)
Abdel Babiker and the Start research team
Physicians for Human Rights – facilitated presentation to Congress
JCRC staff, our patients and all treatment access supporters who have augmented my work