Transcript Slides - View the full AIDS 2016 programme

Imperative of Test and Treat
Peter Mugyenyi
Joint Clinical Research Centre
Kampala, Uganda
Overwhelming evidence
for
Test and Treat
Abundant proof of Survival benefits of ART
Proportion alive
1.0
0.8
0.95
0.92
0.90
0.94
0.90
0.87
164 events
LCM: 2.2/100 PY
CDM:2.9/100 PY
218 events
0.55
0.6
0.4
0.18
0.2
0.08
0.0
0
1
2
3
4
Years from enrolment
5
Entebbe Cohort:
pre-ART 19962000, median
CD4 75 at
enrolment:
57.7/100 PY
DART study results have demonstrated that ART services can be
successfully implemented in rural areas
IAS July 2009
START Study
HIV-infected individuals who are ART-naïve
CD4+ count > 500 cells/mm3
N = 4685
Immediate ART Group
Deferred ART Group
N=2,326
N=2,359
Primary composite endpoint, target = 213
• Serious AIDS or death from AIDS
• Serious Non-AIDS Events and death not attributable to AIDS
o CVD, ESRD, decompensated liver disease, & non-AIDS defining cancers
Early versus deferred initiation of
antiretroviral therapy in HIV-infection
CD4+ cell count
Primary endpoint:
SLIDE from A.Babiker
NEJM 2015
HPTN 052 showed clinical benefit for
earlier ART at <550 CD4 cell count
Number of subjects experiencing >1 event
Delayed
Immediate
Tuberculosis
34 (4%)
17 (2%)
Serious bacterial infection
13 (1%)
20 (2%)
WHO Stage 4 event
19 (2%)
9 (1%)
Oesophageal candidiasis
Cervical carcinoma
Cryptococcosis
2
2
0
2
0
1
HIV-related encephalopathy
1
0
Herpes simplex, chronic
Kaposi’s sarcoma
CNS Lymphoma
8
1
1
2
1
0
Pneumocystis pneumonia
1
0
Septicemia
HIV Wasting
Bacterial pneumonia
0
2
1
1
0
2
Source: Grinsztejn B, et al, Lancet Infectious Diseases, 4 March 2014
7
Simplified communication to the
community
You don't take ART – you die
You start late – you suffer
(& may also die)
HIV treatment:
The most
effective
biomedical
intervention for
the prevention
of HIV
transmission
Strategy to end AIDS epidemic:
how are children doing?
The objective
“Maximize the effectiveness of existing tools
to virtually eliminate progression to AIDS,
premature death and HIV transmission by 2020,
and thereby transform the HIV/AIDS pandemic
into a low level sporadic endemic by 2030.”
Key challenges
• Lack of political will; Commitment of
countries.
• Finances: Increased support from PEPFAR,
GF and donors as countries raise and
commit more resources
• Equity and human rights: Reach all in need
without discrimination using safer and
effective ART
• Laboratory tests: Access to efficient and
affordable laboratory technologies;
Political will
• Leadership and commitment: a demonstrable
success;
–
–
–
–
Uganda leadership lead a prevention program
South Africa: Durban 2000 low ART – Now the worlds largest user
Botswana: Switched to the best available ART
Successes in Rwanda, Thailand, etc
2005 G8 Summit at Gleneagles:
promised universal Access.... “to all those who need it by 2010.”
Finances
• Country obligations:
– Countries to fulfil their own commitments to
increase health sector funding
– Innovate other strategies for raising AIDS
funds; e.g. Uganda tax levy on some luxuries, Zimbabwe,
Kenya etc
Equity & Human rights
• Hard to reach?
– a myth as politicians reach everywhere and everyone during
election campaigns
• Discrimination and stigma:
– Laws that criminalise or discriminate against PLWHIV and others
• Children HIV programs: lagging behind adults as per
self explanatory data.
Disparities Between Adults And Children
(% of ART Coverage Among Adults, Children in 22 Countries
(2012)
Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting.
Note: Some numbers do not add up due to rounding. The coverage estimate is based on the estimated
unrounded number of children receiving and eligible for ART.
Access To Virologic HIV Testing
(Early Infant Diagnosis) 2012
*Lesotho data represents 2011 coverage data
Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting, and UNAIDS
modeling2012 HIV and AIDS estimates.
Roles in effective partnership
Donors and international commitments
• Reduce costly bureaucratic impediments
–
–
–
•
Recipient countries and governments
• Reduce wastage
– Transparency and accountability
– Cost cutting practices:
Involve recipient countries in planning
capacity building
Technology transfer
•
•
•
•
Long term strategies
– Helping poor countries to get out of the
poverty trap
• TRIPS and Patents laws
• International trade agreements
• Justice and human rights
•
•
•
Best clinical practices to minimize
resistance
– Adherence
– Reliable drugs logistics
– Trained human resource
Affordable drugs
Ethical funding
– Do no harm –make a difference
– Long term commitment
– Sustainability
Task shifting,
multi-tasking
Exclude unnecessary tests
Integration of services
•
Good governance,
– developmental policies,
– human rights
Partnering for success
Advocacy/
Political
Normative/
Technical
Financing
R&D
Detractors or just misguided?
“We can’t treat our way through the epidemic”
– words of my co-presenter to the US congress 2010
Can we treat our way through the
epidemic??
Yes, we must
The grim alternative is an epidemic without
foreseeable end, with all the dire human,
social and economic disastrous
consequences.
acknowledgements
1.
2.
3.
4.
5.
DART research team
UNAIDS (Drs Michel Sedibe, Badara Samb et al)
Abdel Babiker and the Start research team
Physicians for Human Rights – facilitated presentation to Congress
JCRC staff, our patients and all treatment access supporters who
have augmented my work