Transcript Francois Venter

Research gaps in treatment
optimization and how Africa can
solve these gaps
Francois Venter
Wits Reproductive Health & HIV Research Institute (RHI)
Nov 2015
So what can we improve? (my in-order-of-priority list)
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Cost
Delivery systems
More convenient HIV testing
Resistance ‘’forgiveness’’
Side effects
Active pharmaceutical ingredients (API)
Size of tablets and packaging
Paeds: need more harmony with adults
SA Snapshot Oct 2015
• 6-7 million HIV positive – 18% world total, 25% of Southern
Africa
• 3.2 million on first line ART – consume 25% of global
generic ART
• 160 000 children – PMTCT working well
• 200 000 on second line, 400 on third line
ART regimens
TDF
XTC
AZT
XTC
EFV
PI
(lopinavir or atazanavir)
XTC, other nukes
Darunavir
Raltegravir
Etravirine
Cost
Cost culprits…
TDF
XTC
AZT
XTC
EFV
PI
(lopinavir or atazanavir)
XTC, other nukes
Darunavir
Raltegravir
Etravirine
Alternatives to TDF cost
• Abacavir too expensive, AZT expensive and
toxic
• Low dose d4T? Not a massive saving, concerns
re long term toxicity – being done in 3 countries
• TAF – TDF pro-drug - potential for BIG savings
(?50%), less API – but NOT being tested with
dolutegravir (more on this later)
• Or could we dump TDF altogether? (DTG/3TC 75% savings!!)
Cost culprits…
TDF
XTC
AZT
XTC
EFV
PI
(lopinavir or atazanavir)
XTC, other nukes
Darunavir
Raltegravir
Etravirine
Containing 2nd line cost
• Stop migration from first line!
• AZT: recycling TDF would be better, but we’d
need more data; dump AZT altogether
• PI: lower doses of darunavir (?atazanavir), or
dolutegravir – large consortium looking at this
Cost culprits…
TDF
XTC
AZT
XTC
EFV
PI
(lopinavir or atazanavir)
XTC, other nukes
Darunavir
Raltegravir
Etravirine
Delivery systems
• Endless ‘’health systems strengthening” – can
we seriously expect the current system to
work?
• Adherence clubs, deliveries at home, kiosks,
vending machines
• Probably needs local tailoring – but not a lot
of scaled innovation
10%
5%
90%
95%
2020
Goal
2025
Goal
49%
51%
Current
coverage
Testing, testing…
PLHIV undiagnosed
• First 90 possibly the hardest
• Innovative operational testing strategies needed
beyond:
– Facility based testing
– Community based testing
– ? Self testing ?workplaces ?key populations ?schools
Thanks WHO: Cheryl Johnson/Rachel Baggaley
Resistance and side effects culprits…
TDF
XTC
AZT
XTC
EFV
PI
(lopinavir or atazanavir)
XTC, other nukes
Darunavir
Raltegravir
Etravirine
Resistance and side effects
• First line:
– ?EFV 400mg vs 600mg (PK work being done)
– Rilpivarine – cheap, good profile (but PMTCT/viral
load/food issue)
– Dolutegravir – almost unbreakable, very good side
effect profile, TB/PMTCT needs sorting – protocol
being designed in SA
• PI: lower dose darunavir (protocol in SA),
??atazanavir
Size of tablet/packaging?
• TAF/FTC/DTG (275mg) vs TDF/FTC/EFV (1.1g)
• Vs DTG monotherapy?
• 2nd line: darunavir 400/100 - ? Single tablet
with rilpivarine or DTG? (400mg DRV study in SA
starting in Jan)
Finally: paeds
• Always left behind, canaries in the mine for
drug stock outs
• Lots of work on DTG; but TDF a problem (?TAF
will solve it)