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Strengthening the treatment cascade Evidence and practice Dr Nathan Ford Treatment and Care Department of HIV. Too few take a test. 8% - 69%. 13% - 76%. 37%. Adults. Pregnant women. Staveteig et al, DHS Comparative Reports, 2013 Global Update on HIV treatment, WHO, 2013. - PowerPoint PPT Presentation
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Excellent healthcare – locally delivered
Strengthening the treatment cascadeEvidence and practice
Dr Nathan FordTreatment and Care
Department of HIV
Too few take a test
Staveteig et al, DHS Comparative Reports, 2013Global Update on HIV treatment, WHO, 2013
8% - 69% 13% - 76%
37%
Adults
Pregnant women
Substantial attrition between testing and ART initiation
Mugglin et al, Trop Med Int Health 2012
15-30% lost at each step
Still too many people start ART late
The IeDEA and ART cohort collaborations
1 in 4 start ART at CD4<100
Cumulative attrition on ART
Global Update on HIV treatment, WHO, 2013
30% LTF at 3 years
Improving testing and linkage
Suthar et al, Plos Med 2013 [Accepted]Global Update on HIV treatment, WHO, 2013
• Partner and couples testing• Community testing• Self-testing• Combination testing• DBS for early infant diagnosis
Enrollment in pre-ART care
Wynberg et al, 2013 (submitted)Kohler et al, AIDS 2011
Enrollment in pre-ART care
• Earlier initiation• PoC CD4• CTX• Adherence clubs
Wynberg et al, 2013 (submitted)Kohler et al, AIDS 2011
CTX prophylaxis
PoC CD4
Adherence clubs
ART initiation
• Task shifting• Decentralization• Service integration
TB/HIV integration India
Paediatric decentralization in Thailand
PMTCT B+ in MalawiGlobal Update on HIV treatment, WHO, 2013Kredo et al, Cochrane Database of systematic reviews, 2013.
Adherence support
• FDCs• Optimized regimens• Viral load• Adherence support (sms, clubs…)
Fixed-dose combinations
Wilkinson, SAJHIV Med 2013; Ford et al, 2013 (submitted); Butler et al, IAS 2013
Summary
• Successful scale up of ART poses continued challenges to current models of care
• Evidence from research and programmes indicate ways to improve patient care at each step of the cascade
• Future research is needed to identify approaches to enroll people earlier onto ART and support long-term retention in care
WHO’s ongoing workto support ART delivery
• Support to regions for guideline rollout • Future of ART monitoring• Phasing out (d4T) and phasing in (viral load)• Early Infant Diagnosis • Paediatric treatment optimization• Cotrimoxazole prophylaxis• Implementation Science summit
Acknowledgements
Gundo Weiler Eric GoemaereVincent Habiyambere Mathias EggerTxema Garcia-Calleja Andrew BoulleMichel Beusenberg Trevor PeterGottfried Hirnschall Lynne WilkinsonMeg Doherty Hein MaraisCadi Irvine Tony Harries Marco VitoriaBoniface Dongmo NguimfackEyerusalem NegussieRachel BaggaleyNathan Shaffer
