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E2: MSF Experience

E2: MSF Experience. Jennifer Cohn, MD MPH MSF Access Campaign. Accelerated Treatment and Decreased Future Burden. Modeling based on Kenyan data. CDC, Division of Global Health, 2012. Enrollment and retention in care. Testing. Staging. Eligibility. ART. Success. Interruptions. 23% 2.

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E2: MSF Experience

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  1. E2: MSF Experience Jennifer Cohn, MD MPH MSF Access Campaign

  2. Accelerated Treatment and Decreased Future Burden Modeling based on Kenyan data CDC, Division of Global Health, 2012

  3. Enrollment and retention in care Testing Staging Eligibility ART Success Interruptions 23%2 LTF LTF LTF LTF 23%3(3 yrs) 41%1 45-56%1 32%1 1. Rosen & Fox, Plos Med 2. Kranzer& Ford, TMIH2011 3. Fox & Rosen, TMIH 2010 4. Brinkoffet al. Plos One 2009 46% RIP4

  4. Survey of 43 PEPFAR-sites >90% of ART initiation and follow up done by doctors Filler et al, JAIDS 2011 Task shifting and decentralization: room for improvement <20% facility coverage for ART in Central African Republic, Guinea, Kenya, Mozambique, and Uganda Getting ahead of the wave: lessons for the next decade of the AIDS response. MSF, 2011

  5. E2: MSF Strategies and Country Ownership Challenges Strategies Models Task Shifting and decentralization Community-based ART Tools POC testing Early initiation of ART Optimized ART Policies • Leaky cascade – user friendliness • Low HRH density • Lack of decentralization • Still in search of optimized ART • Harmonizing with national guidelines vs demonstration projects • Maintaining agile, flexible programs that are country owned

  6. Models: Decentralized Care • Decentralized care in Lesotho • 77% in care at 2 years (Cohen et al, JIAS 2009) Hospitals vs health centres S. Africa: aHR LTF 2.19 (Fatti et al, Plos One 2011) Malawi: 15.3% vs 7.9% (Bemelmans et al, TMIH 2010)

  7. Models: Community ART dispensing in Mozambique • MozOutcomes at 1 year • 98% Remaining in care • 0.2% Defaulting • 2% RIP Decroo et al, JAIDS 2010 Stable patients receive ART from peers in the community

  8. Community support groups, Khayelitsha, South AfricaTowards patient/group self management Median 1029 days on ART at entry RIC at 1y. 99.2%, RIC at 2 y 97.5% vs 85% for clinic-based care Virologic failure halved in CAG vs clinic-based care Group self-management: treatment literacy,defaultertracing March 2012 – 251 clubs across Cape Town MSF Khayelitsha 2011 programme report

  9. Models: Community ART dispensing in DRC DRC: Cost benefits Per patient HRH cost 25 times lower ($230 USD vs $9 USD) Transport costs 3 times lower Waiting time 7 times less (12 min vs 1h25min) Cost savings for health system and patient Jouquet, MSF 2011

  10. Community-Based ART Distribution • Benefits • Increased adherence and RIC (decreased time and cost for patients) • Decreased cost and HRH requirements • Inclusion • Stable patients • In care at least 6 mo (but may decrease as higher CD4 at initiation) • Voluntary • Requirements • Patient ownership • Clear lines of referral • Future directions • New patient populations (children and adolescents, pregnant women)

  11. Tools: Optimizing ART • Dream Regimen • Simple • Tolerable • Durable • Universal • Heat stable • Affordable • Different than PrEP • Short Term: First Line • Best Regimen: TDF/3TC/Efv FDC • Monitor toxicity (renal, bone) • Efvdose reduction (ENCORE-1) • Efv AUC and TB treatment • Induction and maintenance • Rilpivirine • Viral load monitoring • Pediatric regimens • >3 years: Align with adult regimen • <3 years: Better Lpv/r formulations (sprinkle), induction and maintenance options (3NRTI+NNRTI vs PI/r->NRTI) • Short Term: Second Line • ATV/r, LPV/r or DRV/r – need heat-stable FDC or blister packs • Better TB options (alternative boosters, rifabutin FDC) Simple, universal regimens and extended dosing decreases health system burden

  12. Tools: Optimizing ART • Dream Regimen • Simple • Tolerable • Durable • Universal • Heat stable • Affordable • Different than PrEP • Medium Term • Rilpivirine • Induction/maintenance vs higher dose (50) • Boosting • Dose reduce ritonavir or others (cobicistat) • Integrase inhibitors • Dolutegravir(abc/3tc/dtg) – low milligram dose (50mg) – first line • Second line option (e.g. DRV/r/DTG) • Tenofovir pro-drug (GS-7340) • More potent at 1/10 dose • Induction and maintenance • PI/r monotherapy

  13. Tools: Optimizing ART • Dream Regimen • Simple • Tolerable • Durable • Universal • Heat stable • Affordable • Different than PrEP • Long Term • Nanotechnologies • Target sanctuary sites • Improve pharmacokinetics • Reduce toxicity • Delivery systems • Patch, implant, injection • Extended interval dosing • Longer half-life: Elvucitabine, TDF pro-drug • Long acting formulations: rilpivirine, dolutegravir, GSK-744, CMX-157, Elvucitabine

  14. Tools: POC CD4 Jani, The Lancet, 2011

  15. Tools: POC CD4 and Viral Load

  16. Policies and Challenges • ART Recommendations • Accelerating adoption of evidence-based guidelines and effects of GFATM R11 • Simplified PMTCT=? Enough bang for the buck? • Viral load urgently needed • Task shifting and community ART • Task shifting requires supportive regulations and training • CHWs require recognition and remuneration • Optimize ART regimen to facilitate community ART • ART pipeline • Ensuring affordable generics drugs in new IP environment

  17. Thank you! • Sharonann Lynch • Nathan Ford • MSF Access Campaign and Operational Teams

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