1. From "3 by 5" to Universal Access
Kevin M. De Cock
Director, HIV/AIDS Department

2. 25 Years of AIDS 10 Years of HAART Epidemiologic Notes and Reports:
Pneumocystis Pneumonia --- Los Angeles
In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection. Case reports of these patients follow.

3. From "3 by 5" to Universal Access: outline
Current status of HIV/AIDS treatment in the world
Role of the health sector in working towards universal access
Conclusions

4. Dr LEE Jong-Wook

5. Antiretroviral therapy coverage in low- and middle-income countries, June 2006
Geographical region
Number of people receiving ARV therapy
Estimated need
Coverage
Sub-Saharan Africa
23%
Latin America and the Caribbean
75%
East, South and South-East Asia
16%
Europe and Central Asia
24 000
13%
North Africa and the Middle East
4 000
75 000 5%
Total
24%

6. 20 low- and middle-income countries in sub-Saharan Africa, Asia, Latin America and the Caribbean treated more than 50% of those in need, June 2006

7. ARV Therapy: global need, June 20061 5 4
Sub-Saharan Africa
Latin America and the Caribbean
East, South and South-East Asia
Europe and Central Asia
North Africa and
the Middle East 3 2
(Number of people in millions)
Unmet need
Receiving ARV therapy
70% of the total unmet need

8. Women's access to HIV treatment, June 2006
United Republic of Tanzania
Mozambique
Malawi
Zimbabwe
Zambia
Central African Republic
Botswana
Kenya
Côte d'Ivoire
Namibia
Rwanda
Burundi
South Africa
Uganda
Nigeria
10%
40%
50%
60%
70%
20%
30%
Percentage of adults on ART who are women
Percentage of HIV-infected persons who are women

9. Children's access to HIV treatment, June 2006
Median: 8%
Latin America
Africa
Median: 5 %
Asia

10. Access to PMTCT services in sub-Saharan Africa, 200580
Percentage of HIV-infected pregnant women receiving ARV prophylaxis for PMTCT
Togo
Namibia 70
Zambia
Guinea Bissau 60
Benin
Central African Republic
Swaziland 50
Burundi
(Percentage coverage)
Uganda 40
Gabon
Rwanda 30
Kenya
Zimbabwe 20
Lesotho
Mozambique
Côte d'Ivoire 10

11. Treatment access among IDU in Eastern Europe
Serbia
and
Montenegro
Czech Republic
Moldova Estonia Ukraine
100 90 80 70 60 50 40 30 20 10
Lithuania Croatia
Russian
Federation
IDU as % of people living with HIV
IDU as % of people on ART
Change this slide and put % of increase (in 2 slides animated) and show increase by country…

12. Equity of treatment access – knowledge gaps
Coverage and quality of care in:
Time
Place
Person

13. Estimated total annual resources available for AIDS, 1996–2005
Source: Lancet, 2006; 368: 526–30
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
9 000
8 000
7 000
6 000
5 000
4 000
3 000
2 000
1 000
World Bank MAP Launch
Signing of Declaration of Commitment on HIV/AIDS
Global Fund
( US$ millions )
PEPFAR

14. Prices of ARV therapy

15. Comparison of outcome in patients on ART in high- and low-income settings
18 programmes in Africa, Asia, South America (4,810 pts), 12 cohorts from Europe and North America (22,217 pts)
Low-income patients:
- More females (51% vs 25%)
- Lower CD4+ (108 vs 234 per cu mm)
- More NNRTI (70% vs 23%)
Source: ART-Link and ART-CC Groups; Lancet, 2006

16. Comparison of mortality in the months after starting ART in low- and high-income settings16 8 4 2 1 3 5 6 7 9 10 11 12
0.5
(Log scale of mortality rate %)
(Months from starting HAART)
Adjusted hazard ratios
Source: ART-Link and ART-CC Groups; Lancet, 2006

17. CD4 TESTING NOT AVAILABLE
WHO: public health approach to initiating ART
CD4 TESTING AVAILABLE
CD4 TESTING NOT AVAILABLE
WHO CLINICAL STAGING
Treat if CD4 count is below 200 cells/mm3
Do not treat 1 2
Consider treatment if CD4 count is below 350 cells/mm3 and initiate ART before CD4 count drops below 200 cells/mm3
Treat 3
Treat irrespective of CD4 cell count 4
Source: WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access Recommendations for a public health approach, 2006 revision

18. Mortality in patients on ART in low-income settings
73% deaths occurred in persons starting therapy at CD4+ <100 per cu mm
38% deaths occurred in first month, 80% in first 4 months
Source: ART-LINC and ART-CC Groups, Lancet, 2006

19. User fees and treatment outcome
1. Meta-analysis of 10 studies by Ivers LC et al.:
Free laboratory testing did not affect outcome
Free treatment was associated with 29-31% increase in viral load suppression
Source: Ivers LC et al., CID, 2005
2. ART-LINC:
75% lower mortality at 1 year with free treatment
Source: ART-LINC, Lancet, 2006

20. Countries implementing WHO HIV ResNet Drug Resistance protocols
Resistance map

21. Tuberculosis in patients on ART
1. Incidence
Six countries: 3.0 – 17.6 per 100 py
South Africa: per 100 py (CD4+ <200)
1.7 per 100 py (CD )
2. Recurrence
Côte d’Ivoire: per 100 py
Sources: Badri et al., Lancet, 2002; Seyler et al., Am J Respir Crit Care Med, 2005; Bonnet et al., AIDS, 2006

22. Priorities to reduce mortality of HIV/AIDS patients in low-income settings
Expand HIV testing for earlier diagnosis
Ensure essential package of care for HIV-infected patients, including TB screening and co-trimoxazole
Provide ART for Stages 3 and 4 disease as early as possible
Expand CD4+ testing for earlier initiation of ART
Abolish user fees

23. Universal Access 2005 G8 Summit at Gleneagles, Final Communiqué:
“…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.”

24. The health sector's contribution to achieving Universal Access
Expanding testing and counseling
Accelerating treatment scale up
Maximising prevention
Strengthening health systems S T R A E G I C N F
ORMA ON

25. AIDS cases, deaths and persons living with AIDS in the United States, 1985-2003 (CDC)90
450 80
400
AIDS Cases 70
350 60
300 50
250
(AIDS cases and deaths in thousands)
(Persons living with AIDS in thousands) 40
Deaths
200 30
150 20
100 10 50
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
Years

26. Health systems strengthening

27. WHO framework for monitoring the health sector: components of access
Health interventions
Availability:
reachable and
affordable ser-
vices that meet
a minimum
standard
Coverage:
people using
the intervention
among those
who need it
Impact:
reduction in new
infection rates
and improved
survival of
those infected

28. Testing and Counseling
Family VCT
Uganda
Universal TC
Lesotho
Provider-initiated TC
Kenya

29. Routine HIV testing in Botswana
Routine testing in health care settings with right to decline was introduced in 2004
1 268 adults were interviewed
81-93% were in favour, said testing would be facilitated, treatment access enhanced
98% of persons tested expressed no regret
Principal reasons for not testing:
- fear (49%)
- "no reason to believe infected" (43%)
Source: Weiser SD et al, PLOS Medicine, 2006

30. Working towards universal access by 2010

31. Towards Universal Access