2013 WHO Consolidated ARV Guidelines

Summary of Major Recommendations and Estimated Impact

GSG Briefing

July 19, 2013

Gottfried Hirnschall, DirectorHIV Department, WHO

ART Scale up : Progress Towards Global Targets

WHO Global ART report, 2013

Number of pregnant women living with HIV needing Number of pregnant women living with HIV needing and receiving ARVs for PMTCT, 2005-2011and receiving ARVs for PMTCT, 2005-2011

14%

56%

1,570,0001,470,000

HIV+ pregnant women receiving ARVs for PMTCT HIV+ pregnant women needing ARVs for PMTCT

(WHO, Global Report 2013)

Number of children acquiring HIV infection in Number of children acquiring HIV infection in low- and middle-income countries, 1996-2012low- and middle-income countries, 1996-2012

No ARV prophylaxis for PMTCTNo ARV prophylaxis for PMTCT

Current ARV prophylaxis Current ARV prophylaxis coverage for PMTCTcoverage for PMTCT

800,000 800,000 pediatric pediatric infections infections

avertedaverted~290,000 new pediatric ~290,000 new pediatric infections 2012infections 2012

(WHO, Global Report 2013)

2015

2015 goal: 40,000 new 2015 goal: 40,000 new pediatric infectionspediatric infections

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01 | Results: The gap between adult and child ART coverage in 20 high burden countries is widening

Source: Global AIDS Response Progress Reporting (WHO/UNICEF/UNAIDS) and 2013 UNAIDS estimates.

Guidance for Programme Managers

HOW TO DO IT?

•Service delivery •Diagnostics•Drug supply

HOW TO DO IT?

•Service delivery •Diagnostics•Drug supply

HOW TO DECIDE?

•Prioritization•Equity and ethics•Monitoring & Evaluation

HOW TO DECIDE?

•Prioritization•Equity and ethics•Monitoring & Evaluation

WHAT TO DO?

•When to start or switch•Which regimen to use•How to monitor•Co-infections & co-morbidities

WHAT TO DO?

•When to start or switch•Which regimen to use•How to monitor•Co-infections & co-morbidities

Operational

WHO 2013 Consolidated ARV Guidelines

Simplification and consolidation across:

- Continuum of HIV care

- Ages and populations

- Clinical, operational and programmatic guidance

- Existing and new recommendations

Treatment 2.0Treatment 2.0

Clinically relevantoEarlier initiation of ART (CD4 ≤ 500)oImmediate ART for children < 5 yearsoART initiation for all pregnant and breastfeeding women (Option B/B+) and lifelong ART (Option B+)oHarmonization of ART across populations (e.g., adults and pregnant women) and age groups oSimplified, fewer, and less toxic 1st-line regimens (TDF/XTC/EFV)

Clinically relevantoEarlier initiation of ART (CD4 ≤ 500)oImmediate ART for children < 5 yearsoART initiation for all pregnant and breastfeeding women (Option B/B+) and lifelong ART (Option B+)oHarmonization of ART across populations (e.g., adults and pregnant women) and age groups oSimplified, fewer, and less toxic 1st-line regimens (TDF/XTC/EFV)

Key New Recommendations Key New Recommendations in 2013 WHO Guidelinesin 2013 WHO Guidelines

Operationally relevantoUse of Fixed Dose Combinations as a preferred approachoImproved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)oRecommend task shifting, decentralization, and integrationoCommunity based testing to complement broader HTC

Operationally relevantoUse of Fixed Dose Combinations as a preferred approachoImproved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL)oRecommend task shifting, decentralization, and integrationoCommunity based testing to complement broader HTC

Summary of Changes in RecommendationsWhen to Start in Adults

Recommendations: CD4 Independent Conditions

Rationale: Shift from Option A to B+ or BRationale: Shift from Option A to B+ or B

Major issue now is not “when to start” or “what to start” but “whether to stop”Major issue now is not “when to start” or “what to start” but “whether to stop”

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CD4 <350*

on ART CD4 <500* <5y

* incl. co-infected with TB or HBV

** **

** only CD4>500, others included in adults

= 16.7

= 25.9

2010

2010

2013

2013

Number of people eligible for ART in low- and middle-income countries in million per WHO 2010 and 2013 ARV guidelines, based on end of 2012 epidemic situation

Estimated impact on ART eligibility of implementing the new recommendations

Estimated impact on incidence and deaths of Estimated impact on incidence and deaths of implementing the new recommendationsimplementing the new recommendations

WHO Global ART report, 2013

Estimated cost of implementing Estimated cost of implementing the new recommendationsthe new recommendations

WHO Global ART report, 2013

10% increase of the 22-24 billion USD annually for full HIV response

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Child – adult coverage gap is widening,other key populations lag behind

Child – adult coverage gap is widening,other key populations lag behind

Switching from 2010 to 2013 guidelines will enhance impact on lives

& epidemic

Switching from 2010 to 2013 guidelines will enhance impact on lives

& epidemic

15 by 15 is within reach15 by 15 is within reach

Global Update on HIV Treatment 2013: Key Findings and Messages

9.7 million on ART, 1.6 more than in 2011

9.7 million on ART, 1.6 more than in 2011

630 000 children on ART, only 64 000 more than in 2011

630 000 children on ART, only 64 000 more than in 2011

Eligibility increase from 17 to 26 m Mortality/ incidence decline by 1/3 Eligibility increase from 17 to 26 m Mortality/ incidence decline by 1/3

HIV treatment scale-up is paying offHIV treatment scale-up is paying offARVs saved 4.2 million lives and

prevented 800 000 child infectionsARVs saved 4.2 million lives and

prevented 800 000 child infections

Many countries do well, but some need intensified support

Many countries do well, but some need intensified support

In high burden countries, ART coverage varies from 30% to 90%

In high burden countries, ART coverage varies from 30% to 90%

Next Steps• Global level

– Launch of guidelines at IAS KL (30 June 2013)• Full guidelines• Short summaries in 6 UN languages + Portuguese

• Regional level– Regional dissemination workshops

• All regions planned for the next 3-6 months• UN and implementing partners support

• Country level– Country adaptation

• Policy and national guidelines updates• Implementation roll out

22/04/23 16

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Find the New 2013 WHO Consolidated ARV Guidelines on www.who.int/hiv