The Strategic Use of ARVs | IAC Satellite, July 22, 20121 |

Strategic Use of Antiretroviral DrugsWHO Perspective for Future Guidelines

Chair of WHO Strategic and Technical Advisory Committee on HIV

Anthony D HarriesInternational Union Against Tuberculosis and Lung Disease, Paris, France

London School of Hygiene & Tropical Medicine, UK

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1. ART scale-up where are we today?

2. Using antiretrovirals more strategicallywhat are the new opportunities?

3. Making the most of new opportunitieswhat is needed for moving ahead?

4. Moving aheadwhat guidance do we expect from WHO?

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ART scale up – where are we now?Is the 15 million target achievable?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

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2002 2006 2010

WHO’s public health guidelines on ART:from “3 by 5 Initiative” to Universal Access

WHO’s public health guidelines on ART:from “3 by 5 Initiative” to Universal Access

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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 preventionART for treatment and prevention

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Treating HIV infection earlier rather than later 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

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Scenarios for the incremental expansion of ARV provision to treat and prevent HIV

Scenarios for the incremental expansion of ARV provision to treat and prevent HIV

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Treating larger numbers sooner rather than later demands new approaches: Treatment 2.0

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 prioritiesUsing new classes; align regimens across life course; develop new ART strategies

TREATMENT2.0

Adapt delivery systems

Mobilize communities

Providepoint of carediagnostics

Optimize drug

regimens

Reduce costs

New standardized HIV testing strategiesPrequalification of POC CD4 tests

Expand service access and useConvenience and acceptability, i.p. for key populations

Linkages across services, i.p. with chronic care/NCDs

Retain more people in careImprove test-treat-retain chain at every stageExploit all opportunities for contact, incl partners

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Looking forward: WHO consultations on the strategic use of ARVs

Looking forward: WHO consultations on the strategic use of ARVs

1st 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

2nd 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

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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

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WHO’s ARV-related guidance in 2012WHO’s ARV-related guidance in 2012

Treatment as Prevention (TasP)

TasP in sero-discordant couplesLifelong 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

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New “Consolidated ART Guidelines”: key features

New “Consolidated ART Guidelines”: key features

Expanded Guidance Clinical, 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-base Systematic reviews, modelling, cost-effectiveness

Public health approach Universal access and prioritization

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ConclusionConclusion

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