Treatment 2.0 in Latin America and the

Caribbean Baseline and perspectives

XIX

Inte

rnati

onal

AID

S Co

nfer

ence

Washington, DC22-27 July 2012

Dr. Massimo N GhidinelliSenior Advisor, HIV & STI ProjectPan American Health Organization

To accelerate the transition to sustainable and expanded treatment programmes in line with Treatment 2.0• Outline:

– Review the pillars of Treatment 2.0 – Analyze the situation in LAC– Discuss main conclusions that stem from this

analysis

Objective

Patients on ART in LAC2002–2011

2011 ART coverage in Latin America 70%, 67% in the Caribbean, highest in mid-low income settings

WHO. Universal Access progress reports 2010- 2012

Initiations to treatment

192,000 210,000

275,000315,000

345,000390,000

439,000469,000

521,000

577,000

New Infections

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Initiations to treatment

Reach and sustain universal access and capitalize

on preventive benefit of ART

5 pillars to “re-energize” the HIV response…

• Optimize treatment• Provide POC and other simplified diagnostic tools• Reduce costs • Adapt delivery systems• Mobilize communities

Treatment 2.0

Pillar 1. Optimize drug regimens

Objective: Control HIV infectionIncrease duration of each regimen

Sequencing strategies

Rational use Use of fixed dose combinations

SimplificationPhase out inappropriate regimens

Uninterrupted availability of ARVs

Proportions of adult patients receiving WHO recommended regimens , 2010

6

1st line

2nd line

Number of regimens in adultsper line of treatment, 2010

7

Phasing-out obsolete ARVs, 2010

8

7% patients on ART receiving inappropriate ARVs (2010)

ARV Stock-outsMost countries reported > 1 stock out in

2011

9

Country % ART sites with >1ARV stock outs, 2010

Number of ARV stockout episodes,

2010-2011

Antigua and Barbuda

100% ---

Argentina 5% ---Barbados 50% ---Costa Rica 100% ---Cuba 3% ---Dominica 100% ---Ecuador 0% ---Granada 0% ---Guyana 16% ---Haiti 0% ---Jamaica 87% ---Mexico 0% ---Surinam 0% ---Trinidad and Tobago 67% ---Belize 0% ---Chile 0% 0Paraguay --- 0Peru 0% 0Dominican Republic 84% 0Brazil 100% 1Bolivia 0% 1Uruguay 0% 1El Salvador 0% 2Honduras 0% 2Nicaragua 19% 2Guatemala 82% 6Panamá 80% 6Colombia --- 34Venezuela --- 37

PAHO. Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean. 2012.

Regional context

• Limited decentralization of HIV T&C at the primary health care level with complex algorithms and redundant confirmatory tests

• PITC partially implemented mainly in ANC settings• Insufficient impact of HIV testing strategies in key

populations: 50% of MSM with an HIV test in past year; in sex workers a median of 69%

• Legal policy barriers for HIV testing among adolescents

Pillar 2. POC and other simplifieddiagnostic and monitoring tools

Untargeted intensity of HIV T&C(2011)

UN

AIDS

/WHO

. Glo

bal H

IV/A

IDS

Resp

onse

201

1-20

12.

% of patients initiating ART with <200 CD42000-2011

12

Average VL tests per patient on ART2010

13

Viral load / patients on ART

Pillar 3. Reduce Costs

14

Spen

ding

per

pat

ient

on

AR

T (U

SD)

ARV annual spending per patient (2008-2010), USD

  High Medium Low No Dependency  75%-100% % external

funding of ARV20%-75% external

funding of ARV5%-20% external funding of ARV

0%-5% % external funding of ARV

2007-2008

Antigua y BarbudaBoliviaDominicaGranada Guyana Haití JamaicaNicaraguaRepública DominicanaSt. Kitts y NevisSt. Vicente y las Granadinas St. LuciaSurinam

Anguilla BarbadosCubaGuatemala Islas Vírgenes BritánicasMonserrat Ecuador El Salvador Honduras Paraguay BelicePerú

ArgentinaBahamasBrasilChileColombiaCosta RicaMéxicoPanamáTrinidad y TabagoUruguayVenezuela

2011-2012

Antigua y BarbudaBoliviaDominicaGranada Guyana Haití JamaicaNicaraguaRepublica DominicanaSt. Kitts y NevisSt. Vicente y las Granadinas

Anguilla,BarbadosCubaGuatemalaMonserratIslas Vírgenes Británicas St. Lucia

Ecuador El Salvador Honduras Paraguay

Argentina BahamasBrasilChileColombiaCosta RicaMéxicoPanamáTrinidad TabagoUruguayVenezuela BelicePerúSurinam

Dependence of external sources for ARV 2007/2008 -2011/2012

15

“High dependence” countries represent 20%of PLH in the Region

Pillar 4. Adapt delivery systems

• Difficult to characterize service delivery models

• Most ART patients concentrate in tertiary level facilities or dedicated centers

• Limited decentralization of service provision

UNAIDS/WHO. Global HIV/AIDS Response country reported data, 2012.

Percentage alive and on treatment at 12 months of ART initiation, 2011

Pillar 5. Mobilize communities• Strongly organized civil society

at national, sub regional and regional levels. (REDLAC+, CIAT, ECW+, REDCA+…)

• Successful in mobilizing and achieving policies for access to free ART in all countries, and accessing to patented drugs

• CS engaged in T 2.0 but doubts and anxieties about feasibility in LAC, in view of fragility of health systems (i.e stock-outs of ARV and diagnostics)

• Interest in supporting improved availability of information, i.e: GIVAR

1. LAC ready for Treatment 2.0, through contextualized country-based approach, operating on several pillars

2. Strong partnerships, with active involvement of NAP, civil society, international partners, health service-delivery institutions, professional bodies,…key for transition and to synergize public health principles with individualized approaches

3. Ample margins for optimization (regimens, diagnostic algorithms, decentralization of services) and cost reduction. Present “status-quo” unsustainable

4. Building on experience of 1st wave countries, and heightened joint monitoring of implementation plans, move towards sustainable and expanded ART programmes in line with T 2.0

Conclusions

• Monica Alonso• Pedro Avedillo• Beatriz Garcia• Bertha Gomez• Omar Sued• Freddy Perez• Rafael Mazin• Sonja Caffe• …….y otros que han colaborado en el

desarrollo de La Lupa………….

Acknowledgments