Transcript Guidelines - View the full AIDS 2016 programme

WHO Test & treat evidence
and policy mapping
What will it take to make the Test and Start
guidelines a reality?'
Meg Doherty, MD, MPH, PhD
WHO Geneva
Durban, 19 July 20167
Excellent healthcare – locally delivered
What’s new in the ARV Guidelines?
• Treat all - PLHIV of all ages and populations eligible to start at any
CD4 cell count
• Using ARVs for Prevention – Pre-exposure prophylaxis (PrEP) to
prevent HIV among people at significant risk of HIV
• Optimized ARV regimens – new ARV drug classes and better
formulations
• Improved service delivery approaches - to reach all people at all
ages
• Health systems strengthening– to avoid ARV stocks-out and risk
the development of HIV drug resistance
2|
Movement to ‘Treat All’ happening
Policy uptake for adults and adolescents, July 2016
• 24% of all LMIC and 40% of fast track
countries have adopted Treat All
• By the end of 2016, more than half of all
LMIC and 80% fast track countries will
have adopted Treat All
3|
Policy uptake to full implementation,
July 2016
• Implementation is just getting underway and
the majority of countries have not yet fully
put the policy into practice for Treat All
4|
The success story of ‘treat all’ for
pregnant women, July 2016
5|
Policy to Practice for Pregnant Women,
July 2016
6|
Paediatric Treatment Policies, July 2016 –
more variability
• 58% of LMIC and fast track countries will
have adopted treat all for children.
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TDF/XTC/EFV adopted widely,
July 2016
• 90% of LMIC adopted TDF + 3TC (or FTC) +
EFV as the preferred first-line therapy
8|
Regional Variation in Policy Uptake,
July 2016
120
100
80
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
60
40
20
0
% Treat All
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% Treat all +
Plan 2016
% Option B+
%
% Routine VL
TDF/XTC/EFV
Viral Load Challenges: policy into practice
Routine viral load is fully implemented
in 47% of LMIC and partially
implemented in 26% of LMIC.
10 |
10
Improved service delivery through
differentiated models of care
New recommendations for:
• Linkage to care with Rapid initiation of ART
• Adherence
• Retention
• “people-centered” integration with other services including
STIs and NCDs
New policies to improve programme efficiency:
• Less frequent clinic visits
• Less frequent medication pick-up visits for stable patients
• Trained lay providers can distribute ART in the community
11 |
Integrated service delivery
• HIV-Associated TB integration
• ART in MNCH care services
• Comprehensive services for people
who inject drugs
• STIs and family planning services
Uptake of Service delivery recommendations,
July 2016
0.70
0.60
% Children
% Adults
0.50
0.40
0.30
0.20
0.10
0.00
ART in TB
clinics
TB treatment ART in MNCH ART in OST
in ART clinics
clinics
settings
ART in PHC
CHW
ART in the
CVD
MH screening
settings
providing ART community - screening and and treatment
and support differentiated management
byART
care model
by ART
providers
providers
other
Uptake of Co-infection recommendations,
July 2016
Chart Title
1.00
0.90
0.80
% Children
% Adults
0.70
Axis Title
0.60
0.50
0.40
0.30
0.20
0.10
0.00
isoniazid
intensified TB
preventive
case finding in
therapy (IPT) for
PLHIV
people living with
HIV (PLHIV)
TB infection
control in HIV
health-care
settings
co-trimoxazole
prophylaxis
hepatitis B
screening in
antiretroviral
therapy clinics
hepatitis C
screening in
antiretroviral
therapy clinics
Axis Title
hepatitis B
hepatitis C
management in management in
antiretroviral
antiretroviral
therapy clinics
therapy clinics
hepatitis B
vaccination
provided at
antiretroviral
therapy clinics
hepatitis C
treatment
provided in
antiretroviral
therapy clinics
other
Cumulative Incidence (%) of ART Initiation at the Original
Clinic of Enrollment
Cumulative incidence of ART initiation at the original
site of enrollment (CIF curves)
August 2014
CD4<500
WHO III/IV
Pregnant
TB
2004-2010
CD4<200
WHO III/IV
August 2013
CD4<500
WHO III/IV
Pregnant
TB
2004-2007
CD4<200
2010-2014
CD4<350
WHO III/IV
Pregnant
TB
2007-2009
CD4<350
WHO IV
2009-2013
CD4<350
WHO III/IV
Pregnant (2011)
TB
BURUNDI
RWANDA
Threats to quality of system &
EWI of HIVDR
17
Programme Managers Survey – what is
needed to move Treat All
Figure 1: Country HIV epidemic
settings of survey respondents
(N=41)
Generalised epidemic
setting
Figure 2: Top 3 requirements to enable your country to
expand ARV treatment initiation criteria for each of the
groups stated (N=33)
Adults
23%
22%
6%
Children <15
years
23%
20%
11%
Adolescents
22%
15%
29%
Generalised with
specific geographies
of high prevalence
Low prevalence
20%
Pregnant and
breastfeeding
women
23%
Concentrated
epidemic
Positive
person of
s/d couples.
Source: National ART Programme managers
perspectives’ on implementing HIV interventions, KIT
2015
10%
12%
20%
30%
6%
15%
10%
50%
22%
24%
15% 1%
24%
4%
16%
40%
19%
6%
5%
13%
11%
21%
0%
12%
15%
22%
Key
populations
34%
15%
8%
22%
28%
17%
25%
20%
27%
60%
70%
1%
14% 1%
80%
90%
100%
Greater preparation of the health system
Increased local country or MoH funds to expand treatment (health systems and purchasing AR...
A greater desire from the community
More evidence on eligibility
More trained health care workers
18 |
Increased access to donor funds to expand treatment (health systems and purchasing ARVs) I
don’t know
Threats and Responses to Treat All
(Test and Start)
Threats
Responses/Opportunities
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 Evidenced informed interventions &
differentiated service models
 Differentiated models to support
quality, person-centred care
 Incorporate, train, mentor lay workers
 Strengthen M&E, LMIS
 Secure stocks ARVs; price reductions
thru pooled procurement
 Country level financing
Policy gaps
Leaky Cascade
Health Systems
Human resources
Supply Chain Management &
Adequate stocks of goods
 Financing for sustainability
19 |
What is WHO doing to support countries:
Consolidated capacity building workshops
Joint WHO Guidelines Dissemination
Meetings (ARV, HTC, KP, SI)
Locations / Date
Regions
Countries
(108)
21
Number
people (639)
120
PAHO; NAP
15
52
Anglophone
AFR/EMR
Francophone
AFR/EMR
Lusophone AFR
16
130
Trinidad and Tobago PAHO; NAP
March 2016
Colombia
April 2016
S. Africa,
May 2016
Cameroon,
June 2016
Mozambique,
June 2016
Thailand,
August 2016
SEAR/WPR/
EMR/Rwanda
Belarus, September EUR
2016
Outcomes / Next Steps
16
67
5
70
23
130
12
70+
Adoption tools/documents
• Workshop Training Guide
• Policy briefs, fact sheets and Standard
Slide sets in English, French,
Portuguese (Russian, Spanish pending)
• Updated Policy adoption plans for all
countries
• Library of online tools from partner
Market Place
• wi, Nigeria, Mozambique, Angola,
Botswana
Direct Policy Adoption support:
• Nigeria guidelines meeting
• Rwanda Mid/term review and GL
meeting
• Angola guidelines meeting
• Several VL scale up meetings (BKK,
Swaziland, DRC)
• Kenya, Lesotho, S Africa, Malawi,
Mozambique, Angola, Botswana
Acknowledgements
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Michel Beusenberg
Theresa Babovic
Florence Rusciano
Marco Vitoria
Nathan Ford
Martina Penazzato
Shaffiq Essajee
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Olga Tymejczyk (CUNY, IeDEA CA)
Kathryn Anastos (Einstein, IeDEA CA)
Denis Nash (CUNY, IeDEA CA)
Théodore NIYONGABO (IeDEA CA, Burundi)
Christelle Twizere (IeDEA CA, Burundi)
Jean d’Amour SINAYOBYE (IeDEA CA,
Rwanda)
Pacifique Mugenzi (IeDEA CA, Rwanda)
Benjamin Muhoza (IeDEA CA, Rwanda)
Athanase Munyaneza (IeDEA CA, Rwanda)
Rwanda Military Hospital (IeDEA CA, Rwanda)
NIH (1U01AI096299-01) IeDEA Central
African Region (K Anastos and D Nash, MPIs)
SIGN THE
DOTTED LINE
1. DIAGNOSTICS
⇢ No out-of-pocket expenditures for TB tests
⇢ Rapid molecular test (i.e. Xpert) is initial diagnostic for all
⇢ Second-line drug susceptibility testing is available
2. MODELS OF CARE
⇢ Treatment initiation: TB at primary level, DRTB at district/below
⇢ Compulsory hospitalisation is not required
⇢ Immediate ART is offered to people living with HIV
3. DRUG REGULATION
⇢ NTP procures quality-assured TB drugs
⇢ Prescriptions are required for all TB drugs (not over-the-counter)
⇢ TB drugs benefit from accelerated registration
4. DS-TB TREATMENT
⇢ Daily fixed-dose combinations is standard of care
⇢ Treatment, including for children, reflect WHO guidance
⇢ TB contacts are screened, children & PLWHA receive IPT
5. DR-TB TREATMENT
⇢ DR-TB treatment reflects WHO guidance
⇢ WHO recommended DR-TB drugs are on national EML
⇢ New drugs are available via import waivers until full registration
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