Treatment 2.0 in Latin America and the Caribbean Baseline and perspectives XIX International AIDS Conference Washington, DC July 2012 Dr. Massimo N Ghidinelli Senior Advisor, HIV & STI Project Pan American Health Organization

To accelerate the transition to sustainable and expanded treatment programmes in line with Treatment 2.0 Outline: – Review the pillars of Treatment 2.0 – Analyze the situation in LAC – Discuss main conclusions that stem from this analysis Objective

Patients on ART in LAC 2002– ART coverage in Latin America 70%, 67% in the Caribbean, highest in mid-low income settings WHO. Universal Access progress reports Initiations to treatment

Reach and sustain universal access and capitalize on preventive benefit of ART 5 pillars to “re-energize” the HIV response… Optimize treatment Provide POC and other simplified diagnostic tools Reduce costs Adapt delivery systems Mobilize communities Treatment 2.0

Pillar 1. Optimize drug regimens Objective: Control HIV infection Increase duration of each regimen Sequencing strategies Rational use Use of fixed dose combinations Simplification Phase out inappropriate regimens Uninterrupted availability of ARVs

Proportions of adult patients receiving WHO recommended regimens, st line 2 nd line

Number of regimens in adults per line of treatment,

Phasing-out obsolete ARVs, % patients on ART receiving inappropriate ARVs (2010)

ARV Stock-outs Most countries reported > 1 stock out in Country% ART sites with >1ARV stock outs, 2010 Number of ARV stockout episodes, Antigua and Barbuda 100%--- Argentina5%--- Barbados50%--- Costa Rica100%--- Cuba3%--- Dominica100%--- Ecuador0%--- Granada0%--- Guyana16%--- Haiti0%--- Jamaica87%--- Mexico0%--- Surinam0%--- Trinidad and Tobago67%--- Belize0%--- Chile0%0 Paraguay---0 Peru0%0 Dominican Republic84%0 Brazil100%1 Bolivia0%1 Uruguay0%1 El Salvador0%2 Honduras0%2 Nicaragua19%2 Guatemala82%6 Panamá80%6 Colombia---34 Venezuela---37 PAHO. Antiretroviral treatment in the spotlight: a public health analysis in Latin America and the Caribbean

Regional context Limited decentralization of HIV T&C at the primary health care level with complex algorithms and redundant confirmatory tests PITC partially implemented mainly in ANC settings Insufficient impact of HIV testing strategies in key populations: 50% of MSM with an HIV test in past year; in sex workers a median of 69% Legal policy barriers for HIV testing among adolescents Pillar 2. POC and other simplified diagnostic and monitoring tools

Untargeted intensity of HIV T&C (2011) UNAIDS/WHO. Global HIV/AIDS Response

% of patients initiating ART with <200 CD

Average VL tests per patient on ART Viral load / patients on ART

Pillar 3. Reduce Costs 14 Spending per patient on ART (USD) ARV annual spending per patient ( ), USD

HighMediumLowNo Dependency 75%-100% % external funding of ARV 20%-75% external funding of ARV 5%-20% external funding of ARV 0%-5% % external funding of ARV Antigua y Barbuda Bolivia Dominica Granada Guyana Haití Jamaica Nicaragua República Dominicana St. Kitts y Nevis St. Vicente y las Granadinas St. Lucia Surinam Anguilla Barbados Cuba Guatemala Islas Vírgenes Británicas Monserrat Ecuador El Salvador Honduras Paraguay Belice Perú Argentina Bahamas Brasil Chile Colombia Costa Rica México Panamá Trinidad y Tabago Uruguay Venezuela Antigua y Barbuda Bolivia Dominica Granada Guyana Haití Jamaica Nicaragua Republica Dominicana St. Kitts y Nevis St. Vicente y las Granadinas Anguilla, Barbados Cuba Guatemala Monserrat Islas Vírgenes Británicas St. Lucia Ecuador El Salvador Honduras Paraguay Argentina Bahamas Brasil Chile Colombia Costa Rica México Panamá Trinidad Tabago Uruguay Venezuela Belice Perú Surinam Dependence of external sources for ARV 2007/ / “High dependence” countries represent 20% of PLH in the Region

Pillar 4. Adapt delivery systems Difficult to characterize service delivery models Most ART patients concentrate in tertiary level facilities or dedicated centers Limited decentralization of service provision UNAIDS/WHO. Global HIV/AIDS Response country reported data, Percentage alive and on treatment at 12 months of ART initiation, 2011

Pillar 5. Mobilize communities Strongly organized civil society at national, sub regional and regional levels. (REDLAC+, CIAT, ECW+, REDCA+…) Successful in mobilizing and achieving policies for access to free ART in all countries, and accessing to patented drugs CS engaged in T 2.0 but doubts and anxieties about feasibility in LAC, in view of fragility of health systems (i.e stock- outs of ARV and diagnostics) Interest in supporting improved availability of information, i.e: GIVAR

1.LAC ready for Treatment 2.0, through contextualized country- based approach, operating on several pillars 2.Strong partnerships, with active involvement of NAP, civil society, international partners, health service-delivery institutions, professional bodies,…key for transition and to synergize public health principles with individualized approaches 3.Ample margins for optimization (regimens, diagnostic algorithms, decentralization of services) and cost reduction. Present “status- quo” unsustainable 4.Building on experience of 1 st wave countries, and heightened joint monitoring of implementation plans, move towards sustainable and expanded ART programmes in line with T 2.0 Conclusions

Monica Alonso Pedro Avedillo Beatriz Garcia Bertha Gomez Omar Sued Freddy Perez Rafael Mazin Sonja Caffe …….y otros que han colaborado en el desarrollo de La Lupa…………. Acknowledgments