HIV behandeling, een internationaal perspectief

LUT LYNEN DEPARTEMENT KLINISCHE WETENSCHAPPEN ITG

1981: “The beginning of AIDS”

The different faces of AIDS in the early days

HIV prevalence world map

By January 2014, FDA had approved 28 different drugs

Elvitegravir

Dolutegravir

weak and toxic strong and toxic strong and safe

The Dawn of HAART: Combination ART becomes available. “Hit Hard, Hit Early Era”

29.4%

8.8%

http://www.nature.com/nature/journal/v466/n7304_supp/pdf/nature09240.pdf

Bridging the gap

« AIDS exceptionalism »

July 2000: XIII International aids conference, first in Africa

Total available resources for AIDS 1986-2008

19 [i]1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006); [ii] 1986-1993 data: Mann.&. Tarantola, 1996

0 1000

2000

3000

4000

5000

6000

7000

8000

9000

US

$ m

illio

n

292 1623

8.3 billion Signing of Declaration of

Commitment on HIV/AIDS,UNGASS

1995 2000 2005 1987 1990

Less than US$ 1 million

59 212

World Bank MAP

launch

Global Fund

PEPFAR

257

UNAIDS Gates Foundation

10 000 8.9 billion

10 billion

13 billion

2008 2000-2014: 113 billion USD invested in AIDS response in SSA

Price reduction through generic competition

3TC-D4T-NVP

2015: 85% of ARV come from India

Pilot treatment programs from 2002 on

ART scale up in the Developing World

• Access and implementation has been greatly influenced by WHO guidelines – 2002 – 2003 – 2006 – 2010

When to start?

WHO stage 4

or

CD4 < 200

3X5

10X10

Target 2015: 15 M

1996 – Industrialized settings

The Dawn of HAART: Combination ART

becomes available. “Hit Hard, Hit Early

Era” 1

2003 – WHO guidelines

Treatment costs high, ART toxicity is a concern, health

systems are weak “Treat those with greatest need”

2

New knowledge leads to periodic updating of guidelines…

When is Antiretroviral Therapy Started?

• Review of data from 2003-2005 from 42 countries, 176 sites, n=33,008

• Since 2000, CD4 at initiation in developed countries stable at about 175 cells/µl, increasing in Sub-Saharan Africa from 50 100 cells/µl

Egger M, 14th CROI, Los Angeles 2007, #62.

Problem of late start

IRIS

High Rate of Mortality 15% of HIV-infected cohort

Bassett et al. AIDS 2010

1996 – Industrialized settings

The Dawn of HAART: Combination ART

becomes available. “Hit Hard, Hit Early Era”

1

2003 – WHO guidelines Treatment costs high,

ART toxicity is a concern, health

systems are weak “Treat those with

greatest need” (Treat at CD4 < 200)

2006 – WHO guidelines Access improves,

Rx costs lower but late diagnosis as a major

barrier Treat if CD4 < 200, but

consider if < 350 Commitment to UA

2

3

New knowledge leads to periodic updating of guidelines…

Very effective treatment = Lazarus syndrome

HAART effect on life expectancy is enormous in high burden countries

VOILÀ CE QU'UN MALADE DU SIDA DOIT AVALER CHAQUE SEMAINE,

SANS GUERIR POUR AUTANT Complex combinations FDC 1/day

1996 – Industrialized settings

The Dawn of HAART: Combination ART

becomes available. “Hit Hard, Hit Early Era”

1

2003 – WHO guidelines Treatment costs high,

ART toxicity is a concern, health

systems are weak “Treat those with

greatest need” (Treat at CD4 < 200)

2006 – WHO guidelines Access improves,

Rx costs lower but late diagnosis as a major

barrier Treat if CD4 < 200, but

consider if < 350 Commitment to UA

2010 – WHO guidelines Evidence mounting to treat earlier and with

better regimens. Equity key principle

“Treat at CD4 <350” 2

3

4

New knowledge leads to periodic updating of guidelines…

1996 – Industrialized settings

The Dawn of HAART: Combination ART

becomes available. “Hit Hard, Hit Early Era”

1

2003 – WHO guidelines Treatment costs high,

ART toxicity is a concern, health

systems are weak “Treat those with

greatest need” (Treat at CD4 < 200)

2006 – WHO guidelines Access improves,

Rx costs lower but late diagnosis as a major

barrier Treat if CD4 < 200, but

consider if < 350 Commitment to UA

2010 – WHO guidelines Evidence mounting to treat earlier and with

better regimens. Equity key principle

“Treat at CD4 <350” 2

3

4

New knowledge leads to periodic updating of guidelines…

2013 – WHO guidelines “Treat at CD4 <500”

Treatment as Prevention (TASP) 5

2015

Number of people living with HIV on antiretroviral therapy, global, 2010–2015

Sources: Global AIDS Response Progress Reporting (GARPR) 2016; UNAIDS 2016 estimates.

2015 target within the 2011 United Nations Political Declaration on HIV and AIDS

2003 CD4 <200

2016 Treat all

Global ART coverage in 2015 A. 20% B. 40% C. 60% D. 80%

36,7 million HIV infected people

Figure 3

The Lancet HIV 2016 3, e361-e387DOI: (10.1016/S2352-3018(16)30087-X)

Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license Terms and Conditions

Number of people living with HIV receiving ART from 1995 to 2015, and the proportion living with HIV receiving

ART in 2015

Art 9ter

• In 2013: op 9010 dossiers slechts 148 verblijfsmachtigingen (1,6%)

Evolution of HIV diagnoses in Belgium by probable mode of transmission (1995-2015)

www.wiv-isp.be: dec 2015

Art 9ter • Ofwel zeer ernstige ziekte en de patiënt

kan niet meer terug naar zijn land (te ziek) • Ofwel dat er een ernstig risico is op

onmenselijke of vernederende behandeling “wanneer er geen adequate behandeling is in zijn land van herkomst” Dikwijls een zeer letterlijke interpretatie

zonder nuances

Beschikbaarheid van medicatie?

Beschikbaar ≠ toegankelijk

Niet enkel toegang tot medicatie is belangrijk

MSM IVDU

Gevolgen van niet behandelen van mensen met HIV

• Mensen sterven • Mensen verdwijnen, kunnen infecties

doorgeven • Kosten stijgen indien hospitalisatie nodig • Waarom zou men zich laten testen voor

HIV indien geen behandeling mogelijk? • Mensen die niet op behandeling staan

Lut Lynen