Scaling-up HIV/AIDS Care and Treatment Including ART · 2005/4/18 WHO-WPRO; HIV Care 14 WPRO Manage...

Scaling-up HIV/AIDS Care and Treatment

Including ART

Masami FujitaMedical Officer, HIV/AIDS,

WHO/WPRO

Phnom Penh, CambodiaDecember 2004

2005/4/18 WHO-WPRO; HIV Care 2 WPRO

HIV-AIDS global overview 2004

70 millions people already infected1% current world population

30 millions people already passed away

Destroying families, communities, economiesDriving poverty, illiteracyCollapsing health systems & social systemsThreatening securityEntire countries face economic & social collapse


HIV burden in the world


HIV/AIDS burden as of 2004

World Asia/Pacific39.4 million 8.2 million

Adults and children newly infected

4.9 million 1.2 million

Adult and child deaths due to AIDS

3.1 million 0.5 million

Adults and children living with HIV/AIDS


Widening Gap of AIDS Treatment

1.0

0.5

1.5

2.0

1991 19951993 1994 1996 1997 19980.0

AIDS deathsAIDS deathsin Africain Africa

AIDS deaths in Western Europe

Year

ly de

aths

as a

prop

ortio

n of

1995

valu

es

Introduction of HAARTHighly active antiretroviral treatment

1992 1999 2000 2001

Source: Adapted from WHO/UNAIDS Statistics, & HIV/AIDS Surveillance in Europe, End- year report 2001, No. 66, CESES


Extensive efforts made

ART in ART in resourceresource--limitedlimited settingssettings feasiblefeasible

PeoplePeople living living withwith HIV/AIDS HIV/AIDS playplay criticalcritical rolerole

PricesPrices have have beenbeen droppingdropping

FundingFunding isis increasingincreasing (WB, GFTAM, US, etc.)(WB, GFTAM, US, etc.)

Country Country responseresponse building on building on smallsmall scalescale--initiativesinitiatives


The 3 by 5 InitiativeThe 3 by 5 Initiative

WHO, UNAIDS and partners:“Addressing a global public health emergency”

400,000 people receive treatment today

Treat 3 million by 2005Measurable, fixed target towards

the goal of universal access to ART

Accelerating HIV prevention


The 5 pillars of the ‘3 by 5’ strategy

Global leadership, strong partnership & Global leadership, strong partnership & advocacyadvocacy

Urgent sustained country supportUrgent sustained country support

Simplified, standardized tools for delivering Simplified, standardized tools for delivering antiretroviral therapyantiretroviral therapy

Effective, reliable supply of medicines & Effective, reliable supply of medicines & diagnosticsdiagnostics

Learn by doing & rapidly identify & reapply Learn by doing & rapidly identify & reapply new knowledge & successesnew knowledge & successes


Global guiding principles: Three ONEs

hONE agreed AIDS action framework that provides the basis for coordinating the work of all partners

hONE national AIDS coordinating authority with broad based multi-sectoral mandate

hONE agreed country level monitoring and evaluation system

WPRO

Natural Course of HIV Infection and Common ComplicationsNatural Course of HIV Infection and Common Complications

00

100100

200200

300300

400400

500500

600600

700700800800

900900

10001000

00 11 22 33 44 55 11 22 33 44 55 66 77 88 99 1010 1111

CD

4+ c

ell C

ount

CD

4+ c

ell C

ount

AsymptomaticAsymptomaticHZVHZV

OHLOHL

OCOCPPEPPE PCPPCPCMCM

CMV, MACCMV, MACTBTB

TBTB

MonthsMonths Years After HIV InfectionYears After HIV Infection

Acute HIVAcute HIVinfectioninfectionsyndromesyndrome

Relative level of Plasma HIV-RNA

CD4+ T cellsVL


Antriretroviral Treatment (ART)

hControl of HIV replication

hRestoration and/or preservation of immunologic function 8stabilization or increase in CD4 cell count

hReduction of HIV-related complications

hImprovement of quality of life

hIncreased survival


Goals of Therapy

370

710

100

1,000

10,000

100,000

1,000,000

M1 M2 M3 M6 M12 M18 M24050100150200250300350400

Viral load CD4

CD4 count(cells/mm3)

Plasma HIV-RNA(copies/ml)

VL <50

Months on triple therapy

Goal is

undetectable

viral load

13 WPRO

For successful ART

hDo not initiate ARVs too soon:When the CD4 count is high or in patients with no symptoms8If ARVs are started too soon, the patient will incur

the risks of therapy (side effects, viral resistance) without the clinical benefits

hDo not initiate ARVs too late: 8If ARVs are started too late, the patient will be at

high risk for clinical complications of AIDSHowever, it is still possible to start ARV in patents with very advanced disease


Manage OIs and other conditions before ART

h Stabilize OIs and other acute infections before commencing ART, in principle

h TB (next slide)

h Treat esophageal candidiasis but commence ART as soon as can swallow pills

h Anemia (Hb<8): Look for treatable cause (e.g. blood loss, malaria, MAC, etc.), use no-AZT containing regimen

h Pregnancy: Commence ART after the 1st trimester, Avoid EFV for pregnant women or women with the potential

h Conditions which may be improved/resolved with ARTMAC, CMV, Chronic diarrhea, Skin conditions such as PPE, seborrheic dermatitis


WHO Clinical Stage I Asymptomatic

hNo weight losshNo symptoms or only:

Persistent generalized lymphadenopathy

hProphylaxis: INH prophylaxis if eligiblehART: Only if CD4<200


WHO Clinical Stage II Mild disease

hWeight loss 5-10%hSores or cracks around lips (angular cheilitis)hItching rash (seborrhea or prurigo)hHerpes zoster within last 5 yearshRecurrent upper respiratory infections such as

sinusitis or otitishRecurrent mouth ulcers

hProphylaxis: INH prophylaxis if eligibleCotrimoxazole prophylaxis

hART: Only if CD4<200 or TLC <1200/mm3


WHO Clinical Stage IIIModerate disease

h Weight loss >10%h Oral thrush (or hairy leukoplakia)h More than 1 month:

- Diarrhoea- Vaginal candidiasis- Unexplained fever

h Pulmonary TB with last year

h Prophylaxis: - INH prophylaxis if eligible and able to exclude TB- Cotrimoxazole prophylaxis- Other prophylaxis on treatment plan

h ART: - If CD4 not available, treat in all stage 3- If CD4 available, take into consideration CD4<350 when

deciding to treat


WHO Clinical Stage IV Severe disease (AIDS)

hHIV wasting syndrome (WL >10% plus either unexplained chronic diarrhea or chronic weakness and unexplained prolonged fever)

hOesophageal thrush, PCP, Extra-pulmonary TB, CMV retinitis, Cryptococcal meningitis, Toxoplasmosis of the brain, HIV encephalopathy, Lymphoma, Invasive cervical cancer, Kaposi sarcoma,, More than 1 month of Herpes simplex ulcerations (>1 month), etc.

h Prophylaxis: - INH prophylaxis if eligible and able to exclude TB- Cotrimoxazole prophylaxis- Other prophylaxis on treatment planh ART: - All in stage 4 are medically eligible (most OI need to be stabilized before ART)


Adherence Matters

625

5064

81

0102030405060708090

100

70% 90-95% <95%70-80% 80-90%

% p

atie

nts

with

vira

l su

ppre

ssio

n <4

00 c

opie

s/m

l

Percent adherence to therapy

From Peterson et al, 6th Conf ROI 1999 From Peterson et al, 6th Conf ROI 1999 abstrabstr #92#92


Probability of virologic failure

In case, drug taking is like this for many months….

SUN MON TUE WED THU FRI SAT

50 % 75 % 36 %


Key Elements of Comprehensive HIV/AIDS Care and Treatment

Mobilization & coordination of key players incl. PHA Public health and clinical services (incl. TB, ANC/MCH, STI), PHA, CBO, Local authority, FBO and NGOReferral across and within levels for organizing entry points toand continuity of carePromotion of PHA group development and peer supportParticipation of PHA in planning, implementation and evaluation

HIV Testing & Counseling Clinical care

Psychological & socioeconomic support HIV Prevention

Management of OIs including TBART incl. Adherence supportPalliative care incl. Symptom & pain

HIV counselling and spiritual supportEnd of life careSocial welfare and legal supportNutritional and daily living supportStigma & discrimination reduction

Safer sex and condom promotionHarm reductionUniversal precautions and PEPPMTCT

Pre-test education/counsellingHIV testingPost-test counselling

Prolonged quality of life through optimal ART adherenceAccelerated HIV prevention


Identifying level of focus for rapid expansion

hIn Africa where HIV prevalence is very high, decentralized service delivery at PHC/community level is being developed

hIn selected countries in Asia with HIV prevalence of 0.1-3%, what level of service delivery should be the focus?


Provincial/Tertiary

District/Intermediate

Health Centre & Home-Community

- Management of complicated cases- Specialized services & support

- Comprehensive services including ART & coordination- PHA group formation & peer support

- ART adherence support - Basic care

Referral up & down


District or intermediate level of service delivery as the focus

hWith capacity to provide HIV/AIDS clinical management of common OIs & basic ART

hHas sufficient numbers of PHAs to form groups

hIs not too far for PHAs to access care (e.g. transportation)

hNot too close to home and community where stigma and discrimination is still a barrier


HIV Tests OI Drugs- Prophylaxis- Treatment

ARV Drugs

Lab for OI diagnosis& ART monitoring

Provincial/tertiary level

District/intermediate level

Health centre/home-community level

Service packages


ARV Guidelines – WHO December 2003

hFirst line regimen: (d4T or ZDV) + 3TC + (NVP or EFZ)

d4T/3TC/NVP AZT/3TC/NVP d4T3TC/EFV AZT/3TC/EFV

hFixed dose combination (FDC)

Never use AZT & d4T together:Antagonistic


Selection of first line regimen

hd4T: No lab requirement, 30mg (<60kg), 40mg (>60kg)

ZDV: Require hemoglobin check

hNVP: Dose escalation first 2 weeksNot for Refampicin containing TB regimen

EFV: Not for pregnant women


0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

% o

f pat

ient

s pr

ogre

ssin

g

No therapyMono-therapy

Dual-therapy

Triple therapy

Why NOT to use dual and monotherapy

Progression to AIDS/Death

MonthsJAMA 1998 & CMAJ 1999


“4S”

hStarthSubstitute (AZT-d4T, NVP-EFV if toxicity)hSwitch (to 2nd line if failure)

Symptom based- Occurrence of Stage III, IV conditions

(Should not switch in case of IRS)CD4 based- Return of CD4 cell to pre-therapy baseline or below- >50% fall from on therapy CD4 peak level (No other infection to explain transient CD4 decrease)

hStop


Substituting and Switching 1st Line ART Regimen

1st Lined4T+3TC+NVP

2nd LineTDF+ddI+LPV/r

If clinical hepatitisSubstitute

d4T to ZDV

If neuropathy or pancreatitis

SubstituteNVP to EFV

Substitute d4T to ddI (or ABC)

If neuropathy or pancreatitis andsevere anemia

If severe rash

Substitute NVP to EFV

Therapeutic Failure

SubstituteLPV/r to NFV

(or ATV/r)

If renal failure

If severe dislipidemia

If severe GI intolerance

Substitute ddI to ABC SubstituteLPV/r to SQV/r

TB/HIV Substitute

Switch

Substitute TDF to ABC



1st LineZDV+3TC+NVP


If clinical hepatitisSubstitute

ZDV to d4T

If severe anemia or persistent GI intolerance


SubstituteZDV to ddI

(or ABC)

If severe anemia and neuropathy or pancreatitis

If severe rash


Therapeutic Failure


(or ATV/r)Substitute TDF to ABC

If renal failure



Substitute ddI to ABC Substitute LPV/r to SQV/r

TB/HIV DISTRICT/REGIONAL LEVEL

LOCAL LEVEL

Substitute

Switch



1st Lined4T+3TC+EFV

2nd Line TDF+ddI+LPV/r

If severe CNS symptoms or preganacySubstitu

te d4T to ZDV

SubstituteEFV to NVP

If neuropathy or pancreatitis

Substitute d4T to ddI (or ABC)

If neuropathy or pancreatitis andsevere anemia

If hepatitis or severe rash

Therapeutic Failure


(or ATV/r)

Substitute EFV to NFV

If renal failure



Substitute ddI to ABC Substitute LPV/r to SQV/r

TB/HIV Substitute

Switch

Substitute TDF to ABC



1st LineZDV+3TC+EFV


If severe CNS symptoms or pregnancySubstitute

ZDV to d4T

SubstituteEFV to NVP

Substitute ZDV to ddI (or ABC)

If severe anemia and neuropathy or pancreatitis

If hepatitis or severe rash

Substitute EFV to NFV

Therapeutic Failure


(or ATV/r)Substitute TDF to ABC

If renal failure



Substitute ddI to ABC Substitute LPV/r

to SQV/r

TB/HIV

Substitute

Switch

If severe anemia or persistent GI intolerance


Managing OIs & other conditions at “district hospital”

Main symptoms

Disease Prophylaxis Diagnosis Treatment

TB P: INH Smear, CXR NTP regimen

Bacterial pneumonia

P:Cotri. CXR, Smear Antibiotics

PCP P&S:Cotri. Clinical, CXR Cotri.

Toxo-plasmosis

P:Cotri.S:Pyrimethamine+sulfadiazine

Clinical Pyrimethamin+sulfadiazone, orreferral (*)

TB meningitis

P: INH Clinical, Spinal tap

NTP regimen

Bacterialmeningitis

Clinical, Spinal tap

Antibiotics

Diarrhea P: Cotri. (Empirical treatment)

Rehydration fluids, loperamide, antibiotics, metronidazole, cotrimoxazole, mebendazole, (ART)

Crypto-coccossis

S:Fluconazole Spinal tap, Indian Ink

Amphotericin B, flucytosine, fluconazole, or referral (*)

Neurol-ogical

Respir-otory


Managing OIs & other conditions at “district hospital”

Main symptoms

Disease Prophylaxis Diagnosis Treatment

Candidiasis Clinical Topical (gentian violet, nystatin or clotrimazolelozenges), fluconazole or ketoconazole

Peniciliosis S: Itraconazole

Clinical, Smear

Amphotericin B, itraconazole,

Herpes Simplex Clinical Topical, acyclovir if available

Herpes Zoster Clinical Topical, acyclovir if available

PPE, Seb.der. Clinical Steroid (ART effective)

Lymphadenopathy

TB P: INH Clinical, Aspitation

NTP regimen

Fever Septicemia (Empirical treatment)

Antibiotics

Skin & mucosal

An example of laboratory requirement for OI management and ART at “district hospital”


hHIV testinghComplete blood count (CBC) and differentialhPregnancy testhSputum smear for TBhGram and Wright stainshMalaria smearshUrinalysishChest X-Ray

<Preferable>hAlanine Aminotransferase (ALT)hCD4 counthFundoscopy, Spinal tap and Indian Ink stain

A framework for country action on HIV/AIDS Care and Treatment


1. Political commitment, coordination and management: “3 Ones”

2. Uninterrupted supply of affordable HIV medicines and diagnostics

3. Scaling up ART integrated into Continuum of Care

4. Equitable access to care including ARV

5. Responding to diverse and changing situation: M&E

6. Accelerating HIV prevention


Uninterrupted supply of affordable HIV medicines and diagnostics

hHow can it be integrated into existing drug procurement and supply system?

hWhat need to be done differently for HIV medicines and diagnostics?

Date post:	10-Sep-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

Scaling-up HIV/AIDS Care and Treatment Including ART · 2005/4/18 WHO-WPRO; HIV Care 14 WPRO Manage...

Documents