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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
192,000210,000
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 useUse 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
AID
S/W
HO
. 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
Sp
end
ing
per
pat
ien
t o
n A
RT
(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