Maximizing the Prevention Benefit of ART in Asia

1. Maximizing the Prevention Benefit of ART in Asia Ying-Ru Lo, MD, DTM&H World Health Organization Regional Office for the Western Pacific, Manila, Philippines Track C WESY02 Treatment as Prevention in Asia International AIDS Society Conference, 3 July2013 Kuala Lumpur, Malaysia

2. Content • Epidemiology and new evidence • Programmatic challenges • Conclusions

3. Estimated no. of PLHIV by region, 2011 Asia bears the 2nd highest burden of HIV (4.9 million of global total of 34 million) Estimated no. of PLHIV East South and South-East Asia Middle East and North Africa Sub-Saharan Africa Latin America & Caribean Europe and Central Asia Oceania Source: GARP 2012

4. ART coverage in selected countries in Asia, 2011 All ages Only 1 country reached > 80% coverage % ART coverage Country • By the end of 2012 number of people receiving ART • Globally, 9.6 million (64% of global target) • In Asia, 1.3 million Source: GARP 2012

5. Evidence from HPTN 052 • HPTN 052 confirms that earlier ART reduces HIV transmission by 96% among discordant couples in stable relationship (Cohen et al, NEJM 2011) Health Affairs 2012

6. Modelling suggests that HIV testing and ART can avert new HIV infections in Asia • China • 10-fold increase in ART could decrease the number of HIV-related deaths by 58% and the number of new infections by one-quarter by 2015 (Zhang et al, Sexual Health 2011) • Thailand • > 60 % reduction of new HIV cases with increased uptake of HIV testing among key populations and immediate treatment of all HIV-infected people (Peerapatanapokin et al. personal communication) • Vietnam • Annual HTC and immediate treatment for key populations, combined with scale-up of methadone maintenance therapy and condom use, will reduce new infections by 81% compared to current interventions (Kato et al, JAIDS 2013)

7. A combination of interventions has greater impact than an intervention delivered alone

8. Effect of ART at population level depends on …….. • Uptake along the cascade from HIV testing to treatment • Communication across the cascade with improved monitoring and evaluation • Dealing with acute and early HIV infection • Prevention and surveillance of HIV drug resistance

9. Metrics to monitor efficiency of the treatment cascade Vietnam 2011 China 2011 % of people living with HIV % of people living with HIV Source: UNAIDS 2012, VAAC 2011 Source: UNAIDS 2012, NCAIDS 2011 • People with HIV do not know their status • Loss of individuals from HIV testing to care and ART

10. Treatment cascade, Cambodia 2012 Estimated # PLHIV 74,572* (100%) # HIV tested ? ? ? # on ART 48,913 (66%) # in HIV care 6587 (9%) * 2011 Estimates Source: NCHADS 2012 • Increasing # of individuals who know their HIV status • Invest in monitoring

11. Treatment cascade, Thailand, 2008-2011 ? 71% viral load suppression with > 6 months on ART ? No. of people Source: Adapted from Bhakeecheep (Personal Communication), National Health Security Office Thailand 2012

12. Communicating across the treatment cascade • To achieve full impact of treatment, communication across services is critical • The cascade, although broken down by indicators, must be considered as a whole to estimate population-level impact • Requires coordinated programme approach

13. Note on need for unique identifier codes • As we move forward to develop and implement a national unique identifier code for use in the HIV testing, care and treatment cascade, we propose a running number plus additional identifying information, such as year, month, and province of birth, to identify persons as they make their way through the treatment cascade in confined clinical settings Frits van Griensven, Cambodia mission, January 2013

14. 2012 • Individuals with acute HIV infection have 8 to 26-fold higher risk for transmitting HIV vs. those with chronic HIV infection (Pilcher et al, CurrHIV/AIDS Rep 2006, Hollingsworth et al, J Infect Dis 2008, Cohen et al, NEJM 2011) • Relative contribution of early phase of HIV infection (3-6 months after infection) has been extensively modelled with differing results varying between 38% during first 4.8 months of HIV acquisition (Powers et al, Lancet 2011) and 2% during first month of HIV acquisition (Williams and Dye in Cohen et al, Plos Medicine 2012)

15. Monitoring adverse events during earlier ART • HIV drug (antiretroviral) resistance • impact of longer treatment required for earlier ART on resistance is unknown • monitor early warning indicators • Adverse drug reactions • Risk behavior compensation (WEPDB0105, Doyle et al; MOLBPE30, Bavinton et al)

16. Low levels of transmitted HIV drug resistance in Asia, 2005-2010 % of HIV drug resistance among ART –naive individuals from the published literature, by year and region (% with at least one drug resistance mutation), 2004–2010 NS: Not statistically significant. Source: WHO HIV Drug Resistance Report 2012.

17. HIV drug resistance surveillance • As ART roll out continues, increased rates of HIVDR may occur • Routine, standardized, population-based surveillance of HIVDR is imperative and must be in place to detect potential future increase of HIVDR in a timely manner

18. Why ART as prevention implementation research in Asia? • Role of ART as prevention in concentrated HIV epidemics in Asia (SW, IDU, MSM) has not been addressed • What needs to be done differently to achieve the level of effectiveness observed in discordant couples in concentrated epidemics? • What is the cost of expanded HIV testing and earlier ART? • It is likely that earlier ART can be implemented as the pool of infected people to treat is small compared to generalized epidemics

19. Planned implementation research (January 2013)

20. Challenges • HIV testing and counselling uptake is low among key populations • Substantial number of people diagnosed are not effectively linked to care • Attrition is high and adherence suboptimal • Monitoring and evaluation systems do not allow communication across the treatment cascade • HIV drug resistance surveillance is not sustained

21. Treatment as (for) Prevention Gathering necessary information to inform programmes and WHO guidelines Metrics Impact evaluation Implementation & scale-up in countries Support countries on implementation research Serodiscordant couples & programmatic update     • WHO/NIH Cambodia, China, Indonesia, Thailand, Vietnam • TREAT Asia/WHO Treatment as prevention of HIV workshop • WHO China Treatment as Prevention workshop How to improve efficiency of the HIV testing, care and treatment cascade? • WPRO metrics workshop • Support to implementation research in countries • Piloting Unique Identifier Codes • WHO 2013 Guidelines: The use of ARVs for Treating and Preventing HIV 2012 2013 2014 2015

22. Acknowledgements • SorakijBhakeecheep, National Health Security Office (NHSO), Bangkok, Thailand • SuwatChariyalertsak, Research Institute for Health Sciences (RIHES), Chiang Mai University, Chiangmai, Thailand • NittayaPhanuphak, Thai Red Cross AIDS Research Centre, Bangkok, Thailand • Duong Duc Bui, Viet Nam Administration of HIV/AIDS Control (VAAC), Ministry of Health, Hanoi, Vietnam • SengSopheap, National Centre for HIV/AIDS, Dermatology and STD (NCHADS), Ministry of Health, Phnom Penh, Cambodia, • Zunyou Wu, Ye Ma, Fujie Jang, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China • Masami Fujita, WHO Cambodia, Phnom Penh, Cambodia • Masaya Kato, WHO Vietnam Country Office, Hanoi, Vietnam • RaziaPendse, WHO Regional Office for South-East Asia, New Delhi, India • Dongbao Yu, WHO Regional Office for the Western Pacific Region, Manila, Philippines