HIV in the world2009

Joep M.A. Lange

Center for Poverty-related Communicable Diseases

Academic Medical Center / University of Amsterdam

The “failure” of HIV prevention

– Despite positive trends, the number of new infections

outpaces the number of people being put on treatment

(5 : 2)

– Concentrated epidemics with high incidence rates in

particular populations

Why this “failure” of HIV prevention?

– Lack of access to prevention tools (education,

condoms, clean needles, etc.)

– In many contexts behavioral change not an easy

target

– Vulnerable position of women & other populations

Vulnerable postion of women

� Leads to great need for female-controlled

prevention technologies

� Female condoms provide alternative to male

condom, but ultimately still possibility of male

control (apart from cost, etc.)

Apart from increasing access to “classic” HIV prevention tools, what can be done?

– Circumcision yes

– Female condom yes

– Microbicides / diaphragm ?/??

– STD treatment (GUD, esp. HSV2) ???

– Vaccines ??????????????????????????????

– Oral prophylaxis (PREP) ?/(yes!)

– HAART for prevention ?/(yes!)

A concise history of HIV and its treatment in the “developed” world

� 1981: “emergence” of AIDS epidemic in gay men East and West Coast US

� 1983/84: discovery of the causative agent: HIV

� 1987: first active antiretroviral on the market (ZDV)

� 1996: HAART

Why has this been accomplished?

� The presence of substantial markets in the “developed”

world

� An unprecedented civil society movement and

community engagement

Reasons not to introduce HAART in resource-poor settings in 1996

� Too expensive

� Too complex

� Prevention more important than treatment

What has made the difference for the “developing” world?

Money…

� Establishment of funding mechanisms:

– World Bank Multicountry AIDS Program (MAP, 2000)

– Global Fund to fight AIDS, TB and malaria (GFATM,

2002)

– President’s Emergency Plan for AIDS Relief (PEPFAR,

2003/2004)

Leadership

� Community engagement (TASO, etc.)

� Political leadership

� Price reduction of antiretrovirals (Accelerating Access Initiative, etc)

(2000)

� Declaration of Commitment of the United Nations General

Asssembly Special Session on HIV/AIDS (UNGASS) (2001)

� WHO Treatment Guidelines + uptake of antiretrovirals in WHO Model

List of Essential Medicines (2002)

� Target setting: WHO’s “3by5” initiative

However, despite impressive scale-up ,…

� Large number still untreated

– More new infections than people being put on treatment

� Reliance on cheap fixed dose NNRTI-based combinations for first line therapy

– Toxicity

– Durability

� High early mortality rates (because of late treatment start)

� Limited availability of second line options

� Limitid monitoring capacity (no pVL)

Major challenges in the antiretroviral scale-up

� Weak health care infrastructure

� Low numbers of health care workers

� Unreliable supply lines

� Sustainability…?

� Impact of disease-specific programming on fragile health systems…?

Impact of disease-specific (HIV) programming on fragile health systems?

• Lack of good data

• Counters braindrain

• Has upgraded facilities

• Has shown that complacency can be overcome

The AIDS response did create islands of sufficiency in a swamp of insufficiency (Gorik Ooms, MSF)

The way forward

We need to move from AIDS-exceptionalism

to health-exceptionalism

Reality: double burden = double response

Priorities HIV treatment resource-poor settings

� Safer and more robust first line regimens:

– will not only prevent human suffering, but as well save money in the end

– these should be studied in African settings; subtypes may matter!

� Earlier treatment initiation

– requires massive scale up of (VC)T

� Cheap and simple CD4 and pVL tests

� Health systems strengthening (incl. financing)

Mortality over four years

Sub-Saharan Africa

Europe & North America

Months after start of ART

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15

CROI 2007 – mortality - 31

Sub-Saharan Africa

Year

1994 1996 1998 2000 2002 2004 2006

CD

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0

50

100

150

200

250

300

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Europe & North America

MSM

HET

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CROI 2007 – CD4 at start – 11

Median CD4 counts at start of ART Trends over time

SAPIT Study (South Africa) 1

� Starting Antiretroviral therapy at three Points in Tuberculosis therapy (N = 645)

– Early integrated treatment: ART as soon as possible after TB treatment (within two months)

– Later integrated treatment: ART started after the two-month intensive phase of TB treatment is completed (generally month three or four)

– Sequential treatment

SAPIT Study 2

� Safety Monitoring Committee decided to terminate the sequential treatment arm:

– 55% lower death rate in the two integrated treatment arms

– Reduction in mortality significant in both patients with CD4+ cell counts < 200/mm3 and those with counts 200 –500/mm3

� The two integrated arms will continue until 2010 to determine whether there is any difference between those

Parachute Use to Prevent Death and Major

Trauma Related to Gravitational Challenge: Systematic Review of Randomized Controlled

Trials

Gordon C S Smith, Jill P PellBMJ VOLUME 327 20–27 DECEMBER 2003

AbstractConclusions: We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double blind, randomised, placebo-controlled, crossover trial of the parachute. Parachutes’ effectiveness has

not been proven with randomised controlled trials.