Antiretroviral Treatment in South Africa

(Immediate vs Delayed Initiation)

South African Medical Association Conference
18th September 2015
Dr. Nono Simelela
Special Advisor on Social Policy to Deputy
President Ramaphosa
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 Outline
HIV Epidemiology
Global
South Africa
HIV response
Fast Track 90-90-90
South Africa
Rationale for ART scale up
Public health benefit - Treatment as prevention
Individual benefit - Immediate vs Delayed ART Test and Treat
Challenges for Test and Treat
Global and national policy
WHO guidelines, Vancouver statement, SA guidelines
NDOH Consolidated HIV Clinical Guidelines & App
Conclusion & Take Home Messages
HIV EPIDEMIOLOGY
 Global estimates for adults & children
living with HIV - 2014
People living with HIV 37 million [34.3 million 41.4 million]

New HIV infections 2 million [1.9 million 2.2 million]

Deaths due to AIDS 1.2 million [1.0 million 1.5 million]

This means approximately:

5,600 new HIV infections a day
66% are in sub-Saharan Africa
600 are in children <15 years of age
5,000 are in adults 15+ years of age, of whom:
48% are among women
30% are among young people (15-24)
 Adults and children estimated to be living with HIV - 2014

HIV prevalence rising as a result of ART & reduced

mortality and continuing HIV transmission (HIV
incidence falling slowly)
 National HIV Prevalence
Men: 9.9% (est. 2,531,000)
Women: 14.4% (est. 3,873,000)
HIV prevalence by sex and age, South Africa 2012

HIV prevalence up to 8 times higher in adolescent girls

15-19 compared to boys the same age
Estimated new HIV infections per week in young women
(aged 15-24) in East and Southern Africa - 2012

Source: UNAIDS 2013

8
 Overall Context

6.4 million PLHIV 12% of population in 2013

74,083 teenage pregnancies per year
2.4 million children orphaned due to AIDS
Largest ART programme in the world over 3 million people on treatment
Over 600,000 people initiated on ART annually, but LTFU rate is 30-40%
In FY 15/16, over 80% of funding for HIV came from government; rest is
from development partners (PEPFAR, GFATM)
Strong political leadership on HIV
President Zuma lists HIV & TB top of health & development priorities
Deputy President Ramaphosa Chair of SANAC
Minister Motsoaledi first to adopt 90-90-90 for HIV & TB

9
HIV RESPONSE
 Global ART coverage - 2015

Great success story but how do we

take it forwards?
Fast Track Targets
Ending the AIDS epidemic by 2030
 Ambitious, but achievable, new targets

Combines HIV counselling & testing; access to

combination prevention; treatment &
treatment success
 Global Fast Track 90-90-90
Treatment Cascade Targets

Levi J, et al. IAS 2015. Abstract MOAD0102. Reproduced with permission.

 UNAIDS: 90-90-90 Global Estimated Gaps

*HIV-1 RNA < 1000 copies/mL.

Levi J, et al. IAS 2015. Abstract MOAD0102. Reproduced with permission.

Impact of ambitious new targets on HIV infections and
AIDS-related deaths, 2016-2030
HIV Treatment
What FastCascade
Track by 2020 means in South Africa
90-90-90 for HIV:
6.4 million PLHIV
1st 90 - 5.7 million PLHIV know their HIV
status
2nd 90 - 4.1 million PLHIV who know their
status & who are eligible are on treatment
3rd 90 - 3.7 million PLHIV on treatment with
suppressed viral loads
Reduce the annual number of new HIV
infections by 150,000
What Fast Track by 2020 means in South Africa
 What Fast Track by 2020 means in South Africa

90-90-90 for TB
1st 90 - 90% of vulnerable
people screened for TB
PHC attendees
inmates in correctional facilities
miners & peri-mining
communities
2nd 90 - 90% of people with
TB diagnosed & treated
3rd 90 - 90% treatment
success
CAUTION before we start something new!!
RATIONALE FOR ART SCALE-UP
BEYOND CURRENT GUIDELINES
PUBLIC HEALTH IMPACT OF EARLY ART
TREATMENT AS PREVENTION
 HPTN 052 trial highlighted the effectiveness
of treatment as prevention
1736 sero-discordant couples (one partner HIV+) in Botswana, Brazil,
India, Kenya, Malawi, SA, Thailand, Zimbabwe, USA
Immediate vs. Delayed ART for HIV+ partner

Source: Cohen MS, et al. IAS 2011. Abst MOAX0102, Cohen MS, et al. N Engl J Med. 2011
 HPTN052 results show dramatic
reduction in HIV transmission

But these were couples in a clinical trial!

Is this generalizable at a community level?
Could early HIV treatment (regardless of CD4)
on a mass scale reach enough discordant
couples to prevent HIV at population level
Treatment as Prevention?
 Modelling scale up of
Treatment as Prevention strategy
Expanding ART for Treatment & Prevention of HIV in South
Africa: Estimated Cost and Cost-Effectiveness 2011-2050
Assume 90% annual HIV
testing (15-49 yrs)
Expanding eligibility to all
CD4 counts compared to
CD4<350, would by 2050:
o Reduce HIV infections by
3.3m
o Reduce deaths by 3.5m
o Reduce costs by
US$10bn
Costs break even in 2022
Granich, PLoSONE 2012;e30216
 Real life ART scale-up reduces HIV incidence
Hlabisa district KZN Africa Centre
16,667 HIV-negative adults followed 2004-2011
HIV prevalence & ART coverage calculated for 3km
circle around each adult - clever maths & mapping
Risk of HIV seroconversion in relation to ART
coverage calculated
1,413 HIV seroconversions over 53,605 years of
observation

Tanser, Science 2013;339:966

 Hlabisa, Africa
Centre ART coverage
2005 - 2011

Researchers linked:
HIV surveillance database
ART clinic database

HIV prevalence
2005 - 2011

Tanser, Science 2013;339:966

 Direct relation between ART coverage & HIV incidence
Treatment as Prevention - Hlabisa, Africa Centre

Source: Tanser et al. Science 2013;339:966-971

 Early ART the story so far
Treatment as Prevention (TasP)
Evidence base for efficacy (from clinical trials) is
persuasive
Public health benefit
Reduced HIV transmission in couples & communities
Reduced HIV incidence
Public health benefit alone does not justify
treatment as prevention if it means potential
harm to healthy individuals
HPTN 052 not convincing re data on individual
benefits of early treatment
Recently published START & TEMPRANO
studies demonstrate individual benefit
INDIVIDUAL BENEFIT OF EARLY ART
TEST & TREAT
 New Evidence START Study
57% reduced risk of serious events/death with immediate ART

Study closed early by DSMB

following interim analysis

INSIGHT START Group. N Engl J Med. 2015;[Epub ahead of print]. Lundgren J, et al.
IAS 2015. Abstract MOSY0302. Reproduced with permission.
 New Evidence TEMPRANO Study:
Immediate vs Deferred ART Initiation &/or IPT
Delivery for PLHIV in Cote dIvoire

TEMPRANO ANRS 12136 Study Group. N Engl J Med.

2015;[Epub ahead of print].
 Summary of evidence-base for early ART
(test & treat) updated
Evidence base for efficacy is persuasive
Public health
Reduced HIV transmission in couples & communities
Reduced HIV incidence
Individual health
Reduced mortality
Reduced morbidity
TB and other HIV related conditions
Challenge will be effectiveness - taking to massive
scale under programmatic conditions
Real life South Africa!
 Achilles heel(s) of test & treat

Access to HIV Testing

Linkage to care
Retention in care & return to care
Adherence adherence adherence
 Achilles heel(s) of test & treat
Client factors
Socio-economic & demographic factors (disease-related stigma,
transport, age, psychosocial support etc.)
Knowledge , perceptions and beliefs regarding risk, disease,
prevention & treatment
Affective factors (depression, anxiety, shame, etc.)
Behavioural factors (e.g. missed appointments)
Comorbidity, treatment burden, drug side effects & interactions

Health system factors

Human resource capacity skills, tools, attitudes, external stigma
Accessibility - waiting times, distance, lack of integration, centralized
Tracking, recording and reporting
Supply chain management stock outs reliance on global
manufacturing and API
Sustainability escalating costs
Diversity in progress towards the first 90 access to HCT
HIV treatment cascade for people aged 15+
sub-Saharan Africa, 2014
SA Treatment Cascade
3rd 90 VL
suppression
Target 73%
Currently 30%
 3rd 90 - % of PLHIV on ART with viral load suppression
100%

90%
Target 3: 73% of all HIV+ people with
80% HIV RNA Suppression

70% 68%
62% 61%
59% 58%
60% South Africa
52% 52% 30% Code: MOAD01, MOAD0102
50% Title: 90-90-90: Delivering on the Targets
Date: Monday, 20 July 2015
40% Time: 16:30-18:00
40% 35% Room: Ballroom C-D

30% 30% 29%

30%
23%
19% 17%
20% 20%
9% 2%
10%

0%
Switzerland Australia United Denmark Netherlands Rwanda <40 France <50 Brazil <1000 British Cuba (VL USA <200 Sub Saharan Columbia Georgia Estonia Ukraine (VL Russia Cambodia
<200 <400 Kingdom <500 <200 Columbia Unknown) Africa <400 (VL <400 <200 Unknown) <1000 (VL
<200 (Canada) to <40 Unknown) Unknown)
<50
 Starting people on ART is easy
Keeping them on treatment is the challenge
Retention in care

* Note: Y axis starts at 40%

Figures
Figure 1. Average retention at specified time points, by region*

Fox MP, Rosen S, Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income
Countries: Systematic Review and Meta-analysis 2008-2013, J Acquir Immune Defic Syndr. 2015 May
GLOBAL GUIDELINES
WHEN TO START ART
 Global Guidelines on ART
WHO guidelines 2013 Recommend start ART at
CD4<500 currently under review in light of new
evidence
USA & UK recently recommend starting ART at
initial HIV diagnosis regardless of CD4 count
Lancet Vancouver Consensus Statement
IAS HIV Pathogenesis meeting July 2015
Signed by 500 researchers, clinicians & civil society
experts
Recommends all PLHIV should have access to ART at
diagnosis in context of combination HIV prevention
SA Consolidated National Guidelines
SA National Guidelines 1st Jan 2015
Start ART CD4 <500
 NDOH Consolidated HIV Guidelines on
your mobile or tablet!!!
Download for iPhone/iPad on App Store
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HIV Clinical Guidelines App - screenshots
SA Treatment Cascade
 Take home messages CD4 <500 for now..
Dont forget those we are already leaving behind
HIV counselling & testing is critical first step to increase
access to ART
Need to ensure that those tested are linked to care,
started on treatment, kept on treatment and treated
successfully
Adherence will make or break the ART response
Capturing unique patient identifier (national ID number,
passport, drivers license) is only way to track clients
Client experience friendly, competent, fast,
decentralised
All in the context of combination HIV prevention and
non-discrimination
 Acknowledgements
Dr Yogan Pillay NDOH
Prof. Francois Venter WRHI
Dr Graeme Meintjes UCT
Alasdair Reid, Erasmus Morah & Martina Brostrom
UNAIDS