Main Title

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From "3 by 5" to Universal Access
Kevin M. De Cock Director, HIV/AIDS Department
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(No Transcript)
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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

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Antiretroviral therapy coverage in low- and
middle-income countries, June 2006
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21 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
Cambodia
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ARV Therapy global need, June 2006
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Women's access to HIV treatment, June 2006
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Children's access to HIV treatment, June 2006
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Access to PMTCT services in sub-Saharan Africa,
2005
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Treatment access among IDU in Eastern Europe
Serbia and Montenegro
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Equity of treatment access knowledge gaps

• Coverage and quality of care in
• Time
• Place
• Person

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Estimated total annual resources available for
AIDS, 19962005
PEPFAR
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Prices of ARV therapy
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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

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Comparison of mortality in the months after
starting ART in low- and high-income settings
Source ART-Link and ART-CC Groups Lancet, 2006
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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
WHO public health approach to initiating ART
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Mortality in patients on ART in low-income
settings

• 73 deaths occurred in persons starting therapy
  at CD4 lt100 per cu mm
• 38 deaths occurred in first month, 80 in first
  4 months

Source ART-LINC and ART-CC Groups, Lancet, 2006
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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

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Countries implementing WHO HIV ResNet Drug
Resistance protocols

• Resistance map

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Tuberculosis in patients on ART

• 1. Incidence
• Six countries 3.0 17.6 per 100 py
• South Africa 3.4 per 100 py (CD4 lt200)
• 1.7 per 100 py
  (CD4 200-350)
• 2. Recurrence
• Côte dIvoire 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

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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

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Universal Access
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The health sector's contribution to achieving
Universal Access

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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
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Health systems strengthening
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WHO framework for monitoring the health sector
components of access
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Testing and Counseling
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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

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Working towards universal access by 2010
Towards Universal Access
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Towards Universal Access