1. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 1 |1 | Strategic Use of Antiretroviral Drugs WHO Perspective for Future Guidelines Chair of WHO Strategic and Technical Advisory Committee on HIV Anthony D Harries International Union Against Tuberculosis and Lung Disease, Paris, France London School of Hygiene & Tropical Medicine, UK

2. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 2 |2 | 1.ART scale-up where are we today? 2.Using antiretrovirals more strategically what are the new opportunities? 3.Making the most of new opportunities what is needed for moving ahead? 4.Moving ahead what guidance do we expect from WHO?

3. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 3 |3 | ART scale up – where are we now? Is the 15 million target achievable? 54% 6% <200 CD4 but not on ART <350 CD4 but not on ART

4. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 4 |4 | 20022006 2010 WHO’s public health guidelines on ART: from “3 by 5 Initiative” to Universal Access

5. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 5 |5 | HIV-negative persons:  Partners PIP (oral)  TDF2 (oral)  iPrEx (oral)  CAPRISA 004 (topical) HIV-positive persons:  HPTN 052 ART in HIV-positive persons at CD4 > 350 gave clinical benefit and reduced HIV transmission by 96% to the sero-negative partner ART for treatment and prevention

6. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 6 |6 | Treating HIV infection earlier rather than later Likely benefits of earlier initiation –should prevent AIDS and non-AIDS related disease –decreases risk of TB –offers medium and long-term cost saving opportunities but –could increase toxicities and risk of drug resistance –could limit future treatment options –will increase upfront costs

7. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 7 |7 | Scenarios for the incremental expansion of ARV provision to treat and prevent HIV

8. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 8 |8 | Treating larger numbers sooner rather than later demands new approaches: Treatment 2.0 Drug optimization short term priorities: Once-a-day FDC; heat stable PIs; pediatric formulations; phasing out more toxic drugs Drug optimization medium term priorities Using new classes; align regimens across life course; develop new ART strategies TREATMENT 2.0 Adapt delivery systems Mobilize communities Provide point of care diagnostics Optimize drug regimens Reduce costs New standardized HIV testing strategies Prequalification of POC CD4 tests Expand service access and use Convenience and acceptability, i.p. for key populations Linkages across services, i.p. with chronic care/NCDs Retain more people in care Improve test-treat-retain chain at every stage Exploit all opportunities for contact, incl partners

9. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 9 |9 | Looking forward: WHO consultations on the strategic use of ARVs 1 st consultation November 2011: Guidelines Roadmap  Reviewed recent and on-going research  Addressed ART for adults and children, ART impact on other diseases, ARVs for prevention, PMTCT options, PreP, expanded HIV testing  Endorsed roadmap and guideline architecture  Advised on need for interim guidance 2 nd consultation May 2012: Programmatic guidance  Reviewed how strategic and programmatic decisions are made in different situations  Discussed how to prioritize, translate and phase technical recommendations in programmes  Advised on a comprehensive framework for the guidelines

10. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 10 | ART for adults and adolescents guidelines ART for infants and children guidelines PMTCT Guidelines HIV/TB policies and guidance update 2013 Consolidated Guidelines: ARVs for treatment and prevention of HIV Oral PrEP guidance & demonstration projects CHTC guidelines Topical PrEP? Viral hepatitis guidelines The 2015 update Technical notes on operational aspects of PMTCT and treatmten optimization WHO ARV Guidelines Roadmap

11. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 11 | WHO’s ARV-related guidance in 2012 Treatment as Prevention (TasP) TasP in sero-discordant couples Lifelong ART for pregnant women (“B/B+”) TasP in key populations (SW, IDU, MSM) Pre-Exposure Prophylaxis (PrEP) Demonstration projects in sero-discordant couples and MSM

12. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 12 | New “Consolidated ART Guidelines”: key features Expanded GuidanceClinical, programmatic, operational Addressing all ages and populations Adults, women, children, MSM, IVDU, sex workers, prisoners Guidance across continuum of HIV care HIV testing, eligibility for ART, pre-ART care, ART care, ART retention Expanded evidence-baseSystematic reviews, modelling, cost- effectiveness Public health approachUniversal access and prioritization

13. The Strategic Use of ARVs | IAC Satellite, July 22, 2012 13 | Conclusion 1.New benefits of ARVs for treatment and prevention – we need to consider an incremental approach to expanding access to ARVs 2.Treatment 2.0 offers a solid platform for delivering ART to the large numbers of people who will start therapy based on new criteria 3.Consolidated ARV guidelines (combining clinical, programmatic and operational guidance) will help countries chose from a menu of options about who should access ART and how services will be provided