ART in Resource-limited settings : Progress and Challenges

1. ART in Resource-limited settings : Progress and Challenges Dr. B. B. Rewari MD,FRCP,FICP,FIACM,FGSI,FIAMS,FIMSA, NPO (ART) India 21st July 2014, Adult Guidelines India

2. Making of Worlds Second Largest ART Programme Lessons Learnt and challenges ahead

4. Country with the 2ndlargest number of PLHIV on ART • 0.78 million on ART

5. Outline

6. Adapting the 2013 WHO Guidelines • Technical Resource Group (TRG) on Adult ART • Independent technical advisory body • Mandate: reviews guidelines and makes technical recommendations • Programme and financial implementation by NACO

7. 1 2 3 7

8. Technical Challenges • When to start • Earlier threshold • Serodiscordant couples • Hepatitis coinfection • 2. What to start • TDF and EFV in preferred 1st line • Costs • 3. How to monitor • Routine Viral load testing • Other monitoring • Getting “buy-in” • WHO 2013 guidelines are clearly written with details of the evidence around recommendations • Extensive preparations before and for the TRG meetings • Visit to India by a high level WHO team prior to release of guidelines • Knowledge dissemination to programme managers during the WHO regional meetings

9. Other key facilitators in acceptance Guidelines by the national programme • Simplified, standardised, harmonized • Easily adapted for decentralisation and task sharing

10. WHO 2013 Recommendations on When to Start in Adults as accepted by NACO • Early initiation • Option B+ for PMTCT • Offer to SDC

11. Updated India guidelines based on WHO 2013 Recommendations • Simplify • Harmonize • Decentralise • Access++

12. Programmatic Issues: Earlier treatment at CD4< 500 • Not necessarily will improve coverage • Median CD4 for ART start ~ 200 currently • Estimated about 130,000 people enrolled with the programme with CD4 350-500 • Lead to earlier testing and enrollment? • Interaction between ART and co-morbidities in the population • TB, malnutrition, dyslipidemia, renal dysfunction, diabetes, hypertension… • Adherence in asymptomatic PLHIV?

13. Programmatic Issues: Earlier treatment at CD4< 500 • Human resources • Increase patient burden at ART clinics • Dependence on GFATM funding: ART centers located within general health services but funded through GF grant so human resource limitation • Dilution of individual counselling • Time-lag to operationalise (before the next WHO update in 2015) • budgets, procurement, guidelines dissemination, training…

14. Programmatic Issues: What to start – TDF/3TC or FTC/EFV • Costs • TDF+3TC (single pill) + EFV costs USD 110 pppyvs. TDF+3TC+EFV at USD 150 pppy • Limited suppliers • only 2 WHO prequalified companies • Renal screening and TDR toxicities • ? Co-morbidities in the population • Capacity and costs to health system and decentralised care • TDF for children and adolescents Risks vs Benefits

15. Programmatic issues:How to monitor – viral load testing • Quantum of testing and costs: • Targeted VL (10,000 tests p.a) vs Routine VL (800,000 to 1 million tests) • 12 million USD needed in Year 1 only for viral load testing • Human Resources and capacity: • More labs: currently only 9 labs • Sample transport: • DBS still not approved for VL testing • Ability for decentralised testing: • At the moment not possible, predict long turnaround times for results • Point-of-care VL testing in the market (?) Investment and health system strengthening

16. Implementation issues • Strategic approaches to improve coverage for earlier HIV testing and delivery of services • Among key populations eg. self-testing, community testing • Nurse-led for ART maintenance • Decentralisation & cost-effectiveness of delivery models • How far to primary systems in a low and concentrated diverse epidemic? • Strengthening training and quality assurance • Labs, human resource, quality of patient care… • Procurement and supplies

17. Roll-out of the 2013 guidelines • Status • TRG recommended all guidelines accepted except for discordant couple • Procurement of drugs planned and in process • Training modules being revised • Major policy initiative • Decentralisation to Link ART centres • Supply of drugs for three months • Training- revision of guidelines and curriculum • Virus load testing preparation- package of services in PPP model • Dissemination of guidelines • Major service delivery initiative • Decentralization- link centres-FICTC- task shifting • Nurse led model for maintenance being discussed

18. Challenges ahead • Private sector: little data • HIV drug resistance and monitoring Early Warning Indicators (EWI) to prevent this • Pharmacovigilance for ARV toxicities • Convergence/integration with health system without compromising quality • Sustaining quality of care • Sustaining funding and increasing domestic contribution

19. Work intensifies after decisions are made

20. Sustaining Prevention & Addressing Emerging Epidemics Vs The growing ART needs

21. NACP-IV Project Financing NACP-III: $ 1.8 Billion Note: All figures in Charts in Million USD NACP-IV: $ 2.7 Billion • Increase in size of overall envelope • Significant increase in government budgetary support & reduction in donor support

22. The Journey ahead Universal access Decentralization Integration Quality issues

23. Thank You drbbrewari@yahoo.com