TasP for PWID
in low-ressource
settings: challenges and
opportunities
Annual CREIDU-Colloquium: HIV and hepatitis C treatment as prevention
The promise, the pitfalls and the public health benefits
Dr Niklas Luhmann
Harm Reduction and HIV/AIDS Advisor
Médecins du Monde, France
NOUS SOIGNONS CEUX QUE LE MONDE OUBLIE PEU A PEU
Outline of the presentation
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Harm Reduction in Médecins du Monde
TasP for HIV in low ressource settings
TasP for HIV and HCV in PWID
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Myanmar case study
Discussion and conclusion
Harm Reduction in Médecins du Monde
Background: Harm Reduction in Médecins du Monde
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Guiding principles for MdM HR programs:
– Service delivery
– Capacity building and dissemination
– Advocacy:
• Access to HR in Africa
• Acess to viral hepatitis C prevention and treatment
services
• Drug policy reform (national/global)
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Our programs are strongly based in
a community and human rights based approach.
Background: Harm Reduction in Médecins du Monde
ART for HIV/AIDS in MdM :
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Only two remaining programs in which MdM provides ART directly
MdM has no current, specific TasP research
ART elligibility: generally with threshold of CD4 count 350 cells/mm3
General context:
– No full adaption of latest, revidsed 2013 WHO guidelines
– Lack of funding and implementation capacities to fully implement 2013
WHO guidelines in many countries
Background: Harm Reduction in Médecins du Monde
Treatment programs for HCV within MdM:
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No treatment program started yet
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Planning of a treatment program in Tbilissi Georgia:
focus on PWID
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Very high treatment costs (diagnostics and drugs):
only advocacy can bring real change
TasP: Defintion
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WHO working definition of TasP for HIV and TB
(WHO 2012; Programmatic Update Antiretroviral Treatment as Prevention (TasP) of HIV and TB)
ART irrespective of CD4+ cell count for the prevention of HIV and TB. This
includes provision of ART to people living with HIV who are:
– severely immunocompromised with AIDS and/or have a CD4+ count
≤350 cells/mm3
– those with higher CD4+ cell counts >350 cells/mm3
– does not include the use of antiretrovirals (ARVs) for post-exposure
prophylaxis (PEP), pre-exposure prophylaxis (PrEP) and ARVbased microbicides
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N.B.: There is no WHO working definition for TasP for HCV
Background: HIV-TasP in low and middle
income countries
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ART coverage worldwide: 9.7 million people in 2012, with 7.5 million
people in WHO African Region: (WHO, HIV TREATMENT GLOBAL UPDATE ON HIV
TREATMENT, 2013)
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Estimated 15 Million people in need globally with cut-off of CD4 count 350 (
Coverage rate: 65%)
Under latest WHO guidance: if elligibily includes serodiscordant couple,
all pregnant women, children younger than 5 years of age as well as
all patients with CD4 lower than 500 cells/mm3: estimated 25 Million
elligible (USAID, Technical brief, 2012)
Funding crisis: difficulties to increase current coverage rates
Some countries worldwide, such as Zambia, now implement TASP for
serodiscordant couples or in the framework of PMTCT (Option B+). (WHO
2012; Programmatic update)
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No country specifically recommending earlier initiation in key populations
TasP and the (leaky) cascade of care
Main bottlenecks for reaching high numbers of PWID with effective
treatment
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1. Testing: Stigma, criminalization and human rights abuses act as
strong deterrents to accessing testing services
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2. Linkage to care: PWID have often had very bad experiences with
health care system. Support for referral needed.
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3. Enrolling in care and assessing for treatment. Many healthcare
workers have no experience with PWID care.
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4. Maintaining on treatment: Adherence support
Background: HIV-TasP in PWID
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Evidence from Bristish Columbia shows that treatment has a prevention
utility among PWID (Wood E, BMJ 2009)
Combination of NSEP+OST+ART is most effective for HIV prevention
among PWID
From experience we know that people who inject drugs are far less likely to
be considered for ARV programs or enrolment conditional on ‘abstinence’
In 2010, the Reference Group to the United Nations on HIV and Injecting
Drug Use reported that, worldwide, only 4% of HIV-positive people who
inject drugs were receiving ART (Mathers BM, Lancet 2010)
Background: HCV-TasP in PWID
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Different epidemiological models from high-income countries as well as one
model from Vietnam, show considerable prevalence reductions over time among
PWID through treatment with pegINF/RBV (Martin NK et al. Journal of Hepatology 2011;
Hellard ME etal.. Med J Aust 2012; Durier N et al. Plos One 2012)
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The preventive impact may be increased through access to DAA-based treatment
regimens or in contexts with predominant genotypes 2 and 3 among PWID (Martin
NK.et al. Hepataology 2013)
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Combination with high coverage OST and NSEP very important for preventive
effectiveness (Martin NK et al. Clin Infect Dis 2013)
Very little access to HCV treatment in low ressource settings around the world.
Background: TasP in PWID cont.
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Era of biomedical interventions: negative impact on community based prevention
possible (Luhmann, MdM, 2013)
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TasP needs the meaningful involvement of PWID
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Individual vs. public health:
• Benefits have to outweigh the related risks
• Must be voluntary. Public health is not a treatment indication
• Other prevention options may be preferred
TasP must be part of a comprehensive prevention package.
Never stand-alone!
Case study Myanmar
General presentation of the context:
– MdM in Myanmar:
• Harm Reduction program targeting PWID in Kachin State since 1996
• Comprehensive HR approach (including NSEP, OST and ARV) in 3 main sites
– Drug use epidemic:
• Heroin use epidemic is mostly concentrated in regions situated close to poppy
production (Shan and Kachin States)
• Parallel to that, there is also an urban drug use epidemic in large cities such as
Mandalay and Yangon.
– HIV prevalence among PWID:
• HIV prevalence among PWID at national level 18.7% in 2013 (HIV Sentinel
Sero‐surveillance Survey Report, 2013). Slight increase from 18% in 2012.
Case study Myanmar
Coverage of NSEP + OST:
»Estimated
75,000 (range: 60,000-90,000) people inject drugs in the country
(0.23% population prevalence of injecting drug use among 15-64 year-olds)
– NSEP coverage 30% (UNAIDS. 2013)
– Total number of Needles and Syringes distributed in 2013 : 11 Million; 147
syringes/user/year (2013 National Progress report, NAP)
– Total number of people on OST at the end of 2013: 5.9% coverage (4397
patients enrolled) (2013 National Progress report, NAP)
» Coverage of ARVs:
– Number of people receiving ARV at the end of 2013 (NAP): 67,643
– Coverage: 54,1% of all people in need of treatment
– No precise data regarding the number of PWID receiving treatment
Case study Myanmar
Policy context:
» Official eligibility criteria in national guidelines: CD4-count: 350 cells/mm3
and below.
» No mention of particular eligibility for PWID
» Rapid ARV scale up / decentralization process is in itself a huge
challenge for the MoH at the moment.
» Reviewed version of Myanmar national treatment guidelines currently
under discussion: Eligibility may possibly be extended to those with a CD4
count below 500 for sero-discordant couples and Key Affected
Populations (FSW, MSM, PWUD)
» UNAIDS HIV investment case: Needle and syringe programming gives
highest return on investment in terms of overall infections averted (UNAIDS.
Myanmar Invest Now to End AIDS; 2013)
Case study Myanmar
Eligibility criteria in MdM program in 2013:
– Medical eligibility criteria:
» 1. WHO stage 3 or 4
» 2. CD4 < 350 cells/ul
» 3. Patients with active TB disease regardless of CD4 count
– Social eligibility criteria:
» Treatment caretaker obligatory
» Geographical criteria
»Strong
efforts for adherence support in the program: home based visits,
peer support etc.
Case study Myanmar
MdM program data
» Number of different beneficiaries 2013: 6601 PWIDs
reached.
» 2318 were contacted in DIC
» Average CD4 (on first CD4 test done) : Mean=362 (SD
231); Median = 336 (IQR 176-500)
HIV cascade in Myanmar program
2000
1800
1722
1600
1400
Nr of DIC benef
Nr of PWID tested
1200
Nr of PWID HIV+
1000
Nr of PWID enrolled in care
904
Nr of PWID eligible for ART (CD4 350)
800
Nr of PWID started on ART
Nr of patients retained after 12 months
600
400
200
350
274
113
47
0
42
Discussion of Myanmar case study
MdM Kachin programm results:
»‘Only’ 53% of DIC beneficairies are tested
»Rather good linkage to care
»Main bottleneck: Enrollement of elligible patients into ART
»Good retention
Discussion of Myanmar case study
MdM Kachin programm results:
Change of protocol in 2014:
– Social elligibility criteria revised:
• 1. Treatment care taker not obligatory anymore
• 2. No more geographical criteria
• 3. No more selection comitee – but ART meeting
– Medical elligibility criteria:
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1. WHO stage 3 or 4
2. CD4 < 500 cells/ul
3. patients with active TB disease regardless of CD4 count
4. HBV co infected patients with the presence of chronic liver diease
5. Patients with HIV negative regular partner
» Prevention utility was one main argument for the changes
» Shift in paradigm
Conclusion: Making HIV-TasP a
reality in LMICs
Ressources are limited! TasP needs
more funding in low and middle
income countries (LMICs)
Conclusion: Making HIV-TasP a
reality in LMICs
Ressources are limited! TasP needs
political
will
and
increased
implementation capacity
Conclusion: Making HIV-TasP a
reality in LMICs
Access to live-saving treatment is very
limited for PWID, as complex structural
barriers exist in the health care system
and even in HR programs! TasP needs
better drug policies, less stigma and
involvement of people who use drugs!
Conclusion: Making HIV-TasP a
reality in LMICs
Combined
and
comprehensive
strategies are the most effective!
TasP should not be stand alone!
Conclusion: Making HIV-TasP a
reality in LMICs
The treatment cascade often can be
improved! TasP does not only mean
to increase eligibility, but as well
offering high quality services
A word on HCV TasP in LMIC
No TREATMENT ACCESS
=
No TASP
A word on HCV TasP in LMIC
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Preliminary conditions for TasP
– Cost for diagnosis and treatment low!
– All oral treatment regimes with little side effects
– Investement in HCV tretment in genera