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From "3 by 5" to Universal Access

This article discusses the progress made in HIV/AIDS treatment over the past 10 years, from the "3 by 5" initiative to achieve universal access to antiretroviral therapy (ART). It covers the current status of treatment worldwide, the role of the health sector in achieving universal access, and key findings and priorities for reducing mortality in low-income settings.

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From "3 by 5" to Universal Access

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

  2. 25 Years of AIDS 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. 10 Years of HAART

  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 1945-2006

  5. Antiretroviral therapy coverage in low- and middle-income countries, June 2006

  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. Unmet need 70% of the total unmet need 5 Receiving ARV therapy (Number of people in millions) 4 3 2 1 Latin America and the Caribbean East, South and South-East Asia Europe and Central Asia North Africa and the Middle East Sub-Saharan Africa ARV Therapy: global need, June 2006

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

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

  10. Access to PMTCT services in sub-Saharan Africa, 2005 80 Percentage of HIV-infected pregnant women receiving ARV prophylaxis for PMTCT Togo Namibia 70 Zambia Guinea Bissau Benin 60 Central African Republic Swaziland 50 Burundi Uganda (Percentage coverage) 40 Gabon Rwanda 30 Kenya Zimbabwe 20 Lesotho Mozambique Côte d'Ivoire 10

  11. IDU as % of people living with HIV 100 IDU as % of people on ART 90 80 70 60 50 40 30 20 10 Czech Republic Serbia and Montenegro Moldova Estonia Ukraine Lithuania Croatia Russian Federation Treatment access among IDU in Eastern Europe

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

  13. 9 000 8 000 7 000 6 000 5 000 4 000 ( US$ millions ) 3 000 Global Fund World Bank MAP Launch 2 000 Signing of Declaration of Commitment on HIV/AIDS 1 000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Source: Lancet, 2006; 368: 526–30 Estimated total annual resources available for AIDS, 1996–2005 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. 16 Adjusted hazard ratios 8 (Log scale of mortality rate %) 4 2 1 0.5 1 2 3 4 5 6 7 8 9 10 11 12 (Months from starting HAART) Comparison of mortality in the months after starting ART in low- and high-income settings Source: ART-Link and ART-CC Groups; Lancet, 2006

  17. WHO: public health approach to initiating ART Source: WHO guidelines on antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal accessRecommendations 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: 3.4 per 100 py (CD4+ <200) 1.7 per 100 py (CD4+ 200-350) • 2. Recurrence • Côte d’Ivoire: 11.0 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. 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.” Universal Access

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

  25. AIDS cases, deaths and persons living with AIDS in the United States, 1985-2003 (CDC) Persons living with AIDS 90 450 80 400 AIDS Cases 70 350 60 300 50 250 (AIDS cases and deaths in thousands) (Persons living with AIDS in thousands) 40 200 Deaths 30 150 20 100 10 50 0 0 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 Years

  26. Health systems strengthening

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

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

  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 Towards Universal Access

  31. Towards Universal Access

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