What Works? More than 30 years of prevention

and control of HIV

Annette VersterMalta, 30 January 2016

Global epidemiology

Source: UNAIDS 2016 Estimates

Global ART coverage and number of AIDS-related deaths 20002015

36.7 million PLHIV in 2015 (33.4 million in 2010) 2.1 million new infections (2.2 million in 2010)

>35% of new global infections among key populations

Source: UNAIDS special analysis, 2016.

Methodological note: Estimated numbers of new HIV infections by key population were compiled from country Spectrum files submitted in 2015 to UNAIDS (2014 data), available modes-of-transmission studies and additional sources of data drawn from GARPR reports. Where data were lacking, regional medians were calculated from available data and applied to countries populations.

8% MSM7% PWID4% SW16% their sexual partners

WHO 2016-2021 Global Health Sector strategy (aligned with UNAIDS strategy and SDGs)

90% tested

90% Treated

90% suppressed

2020 Prevention targets:

new HIV infections to

Four WHO Packages of HIV Policy Guidance to guide national action

UnderstandStrategic Information

TreatTestPreventin KPs

WHO Focus on Combination Prevention

HIV Testing Services HIV self-testing Assisted partner notification

Male and female condoms and behaviour change Harm reduction for PWID eMTCT/PMTCT PrEP and PEP Prevention benefits of ART VMMC Injection/blood safety Prevention of gender-based and sexual violence

HIV testing services- to identify 1st 90

40% of all PLHIV unaware of HIV status men, adolescents, key populations

Suboptimal linkage post HTS to ART Late initiation of ART

More focus and targeting Balance between HTS approaches in low & concentrated epidemics

Summary of key recommendations Lay providers trained, supervised, remunerated Quality to avoid misdiagnosis Focusing when to retest, diagnosing the undiagnosed Linkages other services, couples and partner testing is highly effective New:

Voluntary and confidential partner notification services can increase uptake of HTS and case finding

HIV Self Testing (HIVST) reactive results need HCP confirmation

WHO guidelines on the use of ART for treating and preventing HIV infection

Treat all across all ages at any CD4 the sickest remain a priority (symptomatic disease and CD4 < 350)

Prevention benefit of immediate ART

Prevent mother to child transmission

Differentiated care packages to optimize the care cascade Refills & clinical monitoring Service delivery: integration, community based services

Comprehensive condom programming

Male and female condoms with lubricant and behaviour change At the centre of a combination prevention approach

Efficient, cost effective and widely available Averted up to 45 million new HIV infections since 1990 and global target for 2020

(90% condom use by people at risk with a non-regular partner) would avert an additional 3.4 million new infections

Annual estimated gap of more than 3 billion condoms in sub-Saharan Africa

Need to increase resources for procurement, distribution and promotion

Diversify products, including female and male condoms and lubricants Develop new approaches to increase use and to enhance the positive

perception of condoms among the various populations in need Engage communities in condom provision and use innovative service

provision mechanisms.

Harm reduction in PWID

The comprehensive package (WHO, UNODC, UNAIDS, 2009) Needle/syringe programmes Opioid substitution therapy Anti-retroviral therapy HIV testing and counselling Prevention and treatment of STIs Condom provision Targeted information, education and communication Prevention and management of viral hepatitis and TB Community distribution of naloxone

Provided in combination and at high coverage levels can reduce up to 50% of new infections in PWID

1. WHO 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations2. Louisa Degenhardt et al Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed Lancet 2010; 376: 285301

OST associated with 54% increase in ART coverage

PMTCT/eMTCT

Source: WHO Policy Uptake data 2016. UNAIDS Global Plan Status Report 2016

1% 1% 1% 1% 2% 3% 5%

15%22%

36%

50%

58%66%

70%75%77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

100,000

200,000

300,000

400,000

500,000

Percentage of PW with HIV receiving ART and new HIV infections in children

>75% of HIV positive PW receive ART and new infections in children have fallen by

60% since the Global PlanIn 2016 88% of 144 LMICs use

Option B+

6 countries achieved eMTCT

PrEP Systematic review HIV Infection outcome

PrEP significantly effective in reducing risk of HIV infection across gender, PrEP regimen, dosing, and mode of acquisition. adherence, effectiveness

Voluntary Medical Male Circumcision

Observational data 1989 2007 RCTs results from Kenya, Uganda and SA:

'in communities with >40% VMMC coverage, male HIV incidence was 0.66 / 100 person year lower than in communities with MMC coverage

Focus on populations, locations and settings with highest HIV risk and transmission

Key populations Disproportionately affected in every region Less likely to access services

24% of PWID, 21% of SW, 14% of MSM living with HIV on ART (compared to 46% global coverage in 2015)

Prisons and closed settings Adolescent girls and young women in sub-Saharan Africa Discordant couples

Need for good strategic information to guide the repsonse

Challenging environment: laws, policies, stigma, discrimination, violence

People who inject drugs Drug use criminalised in most countries, the global war

on drugs fuels negative stereotypes

MSM In 75 countries (plus 5 entities) consensual, same-sex sex

between adults is punishable by imprisonment

New punitive laws introduced

Sex workers Sex workers are particularly subject to sexual and physical

violence exacerbated by criminalisation of their work (>100 countries criminalize some aspects of sex work)

Transgender people In the US, among transgender people surveyed, 55% lost

a job due to bias, 61% were the victim of physical assault and 64% were the victim of sexual assault

Concentration and transmission of HIV, HBV, HCV and TB among prisoners, prison staff and into the community

Period of incarceration and post release provide an opportunity to implement evidence based programmes

Implementation fallen short

Multiple individual and structural barriers along each phase of the incarceration process that prevent implementation of effective measures

Improving the delivery of prison prevention services will require systemic and organisational level changes and health systems strengthening, including collaboration between the criminal justice and public health systems.

Prisons

Challenges

Prevention is difficult More complex to set targets and measure impact

Despite compelling evidence countries remain reluctant to implement and scale up programmes, in particular for KP

Lack of good data, in particular on population size and accessto health services

Continued structural barriers, including Laws and legislation that criminalise behaviours of KP Stigma and discrimination, including in the health sector Lack of appropriate funding

Opportunities

Political Recent global push for prevention

90% coverage 25% of the funds Range of global and regional events

SDGs, UNGASS on AIDS and on World Drug problem WHO Global Health Sector Strategies on HIV, hepatitis and STI

Services New testing possibilities PrEP Vaccin trials in SA Differentiated service delivery Enabeling strategies

Thank you

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What Works? More than 30 years of prevention and control of HIVGlobal epidemiology>35% of new global infections among key populationsWHO 2016-2021 Global Health Sector strategy (aligned with UNAIDS strategy and SDGs)Four WHO Packages of HIV Policy Guidance to guide national actionWHO Focus on Combination PreventionHIV testing services- to identify 1st 90 WHO guidelines on the use of ART for treating and preventing HIV infectionComprehensive condom programmingHarm reduction in PWIDSlide Number 11PrEP Systematic review HIV Infection outcomeVoluntary Medical Male CircumcisionFocus on populations, locations and settings with highest HIV risk and transmissionChallenging environment: laws, policies, stigma, discrimination, violenceSlide Number 16ChallengesOpportunitiesThank youSlide Number 20