From 3by5 to Universal Access – lessons learned and new challenges

ODI Meetings SeriesDo big plans help big numbers?7th June 2006

Prof Charlie GilksDirector, Treatment and Prevention Scale-upDepartment of HIV/AIDSWHO, Geneva

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The start: taking treatment seriously

Big numbers – 6 million+ in need of ART

Almost none (outside Brazil) accessing it

The treatment gap declared a global

health emergency Sept 22, 2003

UN General Assembly, New York

"3 by 5" launched December 1st 2003

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“3 by 5” target and goal

The target is three million people on treatment by the end of 2005

The goal is universal access to anti-retroviral therapy as a human right

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A public health approach to ARTThe goal is to maximise survival at the population level

Provider-initiated testing and counselling• Routine offer of HIV test when treatment available

ART is standardised and simplified• 3 classes of ARVs which are orally available • Two distinct, independent and potent treatment combinations:

first line: NNRTI + 2 NRTIssecond line: bPI + 2 NRTIs (new/not yet used)

Care is standardised and simplified • Clinical decision making and management: the 4 S's of ART • Management of toxicity and drug-drug interactions• Patient tracking and programme M&E

Surveillance and monitoring ARV drug resistance• Population-based rather than individualised

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TDF* or ABC

AZT* or d4T

NVP

EFV3TC or FTC

Triple NRTI alternative approach#

Preferential NRTI/NNRTI approach

# Triple NRTI should be considered as a simplification strategy for 1st line as suggested above, mainly for situations where NNRTIs options provide additional complications ( e.g., pregnancy, viral hepatitis co-infection, TB confection, women who wish to fall pregnant or who have CD4 > 250; NVP or EFV grade 4 SAE; HIV-2 or HIV-0; adolescents).

* Preferential NRTI

1st Line ARV Drugs in Adults and Adolescents

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Trends in the cost of first-line regimens in low-income countries, overlaid with the number of people treated, 2003—2005

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100

200

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2003 2004 2005

Stavudine + lamivudine +nevirapine (US$ per person peryear)

Zidovudine + lamivudine +efavirenz (US$ per person peryear)

Number of people treated at end ofthe year (in thousands)

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0.00

0.25

0.50

0.75

1.00

0 1 2 3 4 5

Two year survival with ART by baseline CD4P

ropo

rtio

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Entebbe Cohort

DART trial

0-49 cells/mm3

50-99 cells/mm3

100-149 cells/mm3

150-199 cells/mm3

Years from cohort entry

"3 by 5" progress December 2005

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Antiretroviral therapy coverage in low- and middle-income countries, December 2005

Geographical Region Number of people receiving ARV therapy Estimated need

Coverage

     (low estimate – high estimate)

   

Sub-Saharan Africa 810 000  (730 000 – 890 000) 4 700 000 17%

Latin America and the Caribbean 315 000  (295 000 – 335 000) 465 000 68%

East, South and South-East Asia 180 000 (150 000 – 210 000) 1 100 000 16%

Europe and Central Asia 21 000  (20 000 – 22 000) 160 000 13%

North Africa and the Middle East 4 000 (3 000 – 5 000) 75 000 5%

Total 1 330 000 (1 200 000 –1 460 000) 6.5 million 20%

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Number of people receiving ARV therapy in low and middle income countries, 2002—2005

end2002

mid-2003

end2003

mid-2004

end2004

mid-2005

end2005

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100

200

300

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500

600

700

800

900

1 000

1 100

1 200

1 300

1 400

Pe

op

le r

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AR

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rap

y (

in t

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)

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

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Percentage of people in sub-Saharan Africa on antiretroviral therapy among those in need

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Percentage of women among all adults receiving antiretroviral therapy, 2005

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Scaling up of antiretroviral therapy in Malawi, 2003—2005

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Beyond 3 by 5 … to Universal Access

Communiqué of G8 Summit in Gleneagles 2005

"With the aim of an AIDS-free generation in Africa, significantly reducing HIV infections and working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care,

with the aim of as close as possible to universal access to treatment for all those who need it by 2010"

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Lessons learned from 3x5 …ART is finally an integral and core component of the

national response to HIV/AIDS • Prevention alone does not work well• ART alone is unsustainable• No false dichotomies … Prevention or ART

Evidence-based standards for prevention care and ART• Evidence poorly collated and synthesised• Relevant data not always collected (esp. for public health approach)

Coordinated responses mandated: the 3 ones• Multiplicity of players• Great number of responses

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Lessons learned from 3x5 …

Target-driven approach to public health works• National NOT global: accountability and ownership• Simple and tangible for political buy-in• Prevention targets – but this is never "sexy"

Simple commodities / formularies for treatment• Procurement and supply management• Market place for products• First-line; now paediatric ART and second-line

Tracking progress to show successes• Donors to show effectiveness of spend• Civil society to hold governments accountable• Measurable targets

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Challenges …

Ensure prevention is not left behind• Prevention better than "cure"• Prevention not as appealing• Prevention targets difficult• Multisectoral and many partners

Chronic disease management• Beyond the numbers starting• Quality of care for life• Person-centred care in the community

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Dr LEE Jong-wook 1945 - 2006