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Review of Global Guidelines from 160 countries

Review of Global Guidelines from 160 countries Please note that this is “under construction” and is a dynamic area – policies are changing and we do not have written policies for some countries – let us know if you see errors and/or there are new policies for the database.

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Review of Global Guidelines from 160 countries

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  1. Review of Global Guidelines from 160 countries Please note that this is “under construction” and is a dynamic area – policies are changing and we do not have written policies for some countries – let us know if you see errors and/or there are new policies for the database Last updated: October 2016

  2. Objectives and methodology: “wiki strategy” Web search UNAIDS regional support team Objective: Compare national ART guidelines for 160 countries with WHO 2015 guidelines Published guidelines from 122 countries* and recommendations from 38 countries Ministry of Health officials AIDSTAR-One database Recommendation on ART initiation criteria and monitoring for different target population abstracted Search end date: October 2016 * 15 countries with old version of guidelines

  3. ART initiation for asymptomatic people Source: published policy

  4. WHO recommendations and published national guidelines (2003-2016) Countries in the green boxes were consistent with the WHO ART guidelines in a given year, countries in blue boxes were recommending early ART compared to WHO guidelines while countries in red boxes were recommending delayed ART compared to WHO guidelines.

  5. <200, <250 or <300 ART initiation for asymptomatic people <350 <500 2015 WHO Recommendation : Irrespective of CD4 count >500 Irrespective of CD4 count Source: published policy

  6. <200 ART initiation criteria in Africa <350 <500 2015 WHO Recommendation : Irrespective of CD4 count Irrespective of CD4 count Source: published policy

  7. IDENTIFICATION (98) 98 guidelines from 37 countries identified from the Internet, Ministries of Health, WHO, UNAIDS, CDC, USAID, PEPFAR, NGOs, HIV experts and members of the community Policy Lag in Sub-Saharan Africa – Methods Excluded 4 countries that have reported move to CD4 <350 or earlier but latest guidelines are not available (an old version recommending ART at CD4 <200 available for each country) SCREENING (94) 94 guidelines from 33 countries (2001-2016) screened Excluded 29 guidelines from 16 countries that did not contribute to calculating the time to adoption of the WHO 2009, 2013, or 2015 guidelines (countries published multiple guidelines before 2009) DATA COLLECTED (65) From 65 guidelines from 33 countries, data were collected on month and year of publication, and ART eligibility criteria DATA ANALYSIS Average time lag in adoption of the WHO 2009, 2013 and 2015 guidelines calculated and analyzed Source: Gupta, Granich (2016) - updated

  8. Policy Lag in Sub-Saharan Africa (33 countries) Source: Gupta, Granich (2016) * Assumption: 8 remaining countries move to CD4 <500 or earlier in September 2016

  9. Timeline showing release of WHO guidelines and guidelines from 33 countries in Sub-Saharan Africa 2006 - 2008 Jan – Aug 2015 2012 2010 Jan - July 2016 Jan - Sep 2009 2011 June - Dec 2013 2014 June 2013 Oct 2009 Sep 2015 JANUARY Swaziland 2006 Sierra Leone JUNE Niger FEBRUARY Angola JANUARY Mozambique JUNE Cote d’Ivoire JANUARY Namibia Sudan JANUARY Swaziland APRIL Lesotho APRIL Botswana South Africa Tanzania MAY Zimbabwe JUNE Guinea Uganda MAY Tanzania MAY Malawi MARCH South Sudan 2007 Lesotho Rwanda JUNE Ethiopia Madagascar JUNE Zambia JUNE Botswana JULY Malawi JULY Democratic Republic of the Congo 2008 Mali Djibouti Ghana Burkina Faso APRIL Lesotho Malawi JULY Namibia JUNE Benin JULY Kenya Rwanda WHO 2013 guidelines (CD4 <500 cells/mm3) WHO 2009 guidelines (CD4 <350 cells/mm3) NOVEMBER Kenya WHO 2015 guidelines (Irrespective of CD4 count) OCTOBER Ethiopia JUNE Cameroon Gabon Kenya Nigeria AUGUST Democratic Republic of the Congo NOVEMBER Mali SEP Mozambique South Africa DECEMBER Rwanda Uganda Zambia Zimbabwe OCTOBER Burundi Nigeria AUGUST Burundi Mauritania DECEMBER South Africa Note: Red box denotes move to the WHO 2009 guidelines [CD4 count <350 cells/mm3], green box denotes move to the WHO 2013 guidelines [CD4 count <500 cells/mm3], and blue box denotes move to the WHO 2015 guidelines [irrespective of CD4 count].

  10. Reported ART initiation criteria in 53 countries (missing written policy document)

  11. ART initiation for asymptomatic people Source: published policy + reported

  12. <200, <250 or <300 ART initiation for asymptomatic people <350 <500 2015 WHO Recommendation : Irrespective of CD4 count >500 Irrespective of CD4 count Source: published policy + reported

  13. <200 ART initiation criteria in Africa <350 <500 2015 WHO Recommendation : Irrespective of CD4 count Irrespective of CD4 count Source: published policy + reported

  14. GDP per capita and ART coverage

  15. National policy on task shifting Nurses can initiate ART and lay workers can provide ART adherence counselling Neither nurses can initiate ART nor lay workers can provide ART adherence counselling Lay workers can provide ART adherence counselling Nurses can initiate ART Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  16. National policy on ARV drug dispensing 2-3 month routine drug refills for people in stable condition and ARV dispensing at community level ARV dispensing is not recommended 2-3 month routine drug refills for people in stable condition ARV dispensing at community level Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  17. Task shifting and ARV drug dispensing Source: MSF UNAIDS. Speed up scale-up: Strategies, tools and policies to get the best HIV treatment to more people, sooner

  18. ART eligibility criteria for children below age of 15 2015 WHO Recommendation : Irrespective of CD4 count • Of the 122 countries with guidelines, 87 countries (91% burden) have recommendations on paediatric ART • ART initiation criteria for children <15 vary considerably • Of the 87 countries, 13 (47% global paediatric burden) are consistent with WHO 2015 guidelines

  19. ART eligibility criteria for children <15 years WHO 2015 Guidelines: ART irrespective of CD4 count Source: published policy

  20. ART eligibility criteria for children <15 years WHO 2015 Guidelines: ART irrespective of CD4 count Clinical prerequisites ART for all children <1 ART for all children <2 ART for all children <5 ART for all children <15 Source: published policy

  21. 2004 - 2005 2015 2012 2010 2016 2006-2009 2011 2013 2014 <15 years Tanzania <15 years Namibia, Uganda, Zambia <15 years US <2 years Guyana <1 year Brazil, Burkina Faso, Sweden WHO paediatric recommendations and published national guidelines (2004-2016) Pre-requisites Cape Verde Pre-requisites Comoros, Djibouti, Lao People’s Democratic Republic, Liberia, Malaysia, Peru, Philippines, Sierra Leone, Ukraine <2 years Algeria, Ghana, Morocco <2 years Afghanistan Kazakhstan Panama, Timor-Leste <2 years Argentina, Benin, Papua New Guinea <5 years Colombia, Democratic Republic of Congo, Fiji, Honduras,Mali, Oman, Zimbabwe <15 years Botswana, China Kenya Lesotho, Malawi, South Africa Mozambique Rwanda <5 years Angola, Bangladesh, Bhutan, Burundi, Cameroon, El Salvador, Gabon, Indonesia, Nigeria, Mauritania, Myanmar, Nepal, South Sudan, Sudan <5 years Cambodia, Maldives, Pakistan, Swaziland, Viet Nam <2 years Cote d’Ivoire,Haiti, India, Marshall Islands, Samoa, Tuvalu, Vanuatu <2 years Venezuela <1 year Paraguay <1 year Ethiopia, Guatemala <1 year Costa Rica, Finland, Mexico, Sri Lanka, Thailand, Uruguay Pre-requisites Guinea <1 year Chile, Russia Dominican Republic, Hong Kong, Madagascar, Romania, Tunisia

  22. ART initiation for people with HIV and TB Source: published policy

  23. ART initiation for pregnant women Source: published policy

  24. ART initiation for serodiscordant couples 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  25. ART initiation for people with Hepatitis B 2015 WHO Recommendation : Irrespective of CD4 count Source: published policy

  26. ART initiation criteria for key populations 2015 WHO Recommendation : No specific recommendation Source: published policy

  27. ART initiation criteria for key populations 2015 WHO Recommendation : Irrespective of CD4 count Earlier ART for KPs No recommendation specific for KP Irrespective of CD4 count for KP Irrespective of CD4 count for all, including KP Source: published policy KP: Key populations

  28. Frequency of CD4 monitoring (55 countries)

  29. Viral load monitoring (55 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  30. Frequency of routine VL (47 countries) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  31. Availability of Viral Load (55 countries) Recommended and widely available Recommended (availability unknown) Recommended with limited availability Recommended only for monitoring treatment failure Not recommended No recommendation (limited availability) Source: MSF Issue Brief: Achieving undetectable: what questions remain in scaling-up HIV virologic treatment monitoring?

  32. Availability of IPT (24 countries) Recommended and widely available Recommended (availability unknown) Not recommended Recommended with limited availability

  33. Night sweats Night sweats Night sweats Night sweats Night sweats Night sweats TB exclusion criteria for IPT (24 countries) Weight loss Weight loss Weight loss Weight loss Weight loss Weight loss Fever Fever Fever Fever Fever Fever Cough Cough Cough Cough Cough Cough WHO recommendation CAMEROON ETHIOPIA INDIA KENYA LESOTHO MALAWI MYANMAR SWAZILAND UGANDA VIET NAM ZAMBIA MOZAMBIQUE Coughing blood TANZANIA INDONESIA NAMIBIA NIGERIA THAILAND Shortness of breath SOUTH AFRICA Shortness of breath TST Enlarged nodes Coughing blood Enlarged nodes Enlarged nodes TST BRAZIL TST Recommendation not available for China, DRC, and Zimbabwe. IPT is not recommended by Cote d’Ivoire and Botswana

  34. Limitations • Guidelines may be outdated and/or in the process of being updated • Written policies may not reflect programme implementation or clinical practice • Other guidelines covering ART, task shifting, drug dispensing may exist

  35. Conclusion • Guidelines from 21 countries released before 2015 recommend ART for asymptomatic people irrespective of CD4 count • 33 countries (44% global burden) recommend test and treat • Only 13 countries are consistent with the 2015 WHO paediatric ART recommendation • Post 2015 WHO guidelines, countries are revising/ planning to revise national guidelines

  36. www.HIVpolicywatch.org Please send new and/or updated guidelines to: Reuben Granich MD MPH Vice President and Chief Technical Advisor, IAPAC E-mail: rgranich@iapac.org

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