WHO Target 90-90-90 : Achievable for Latin America
Dr. Alejandro Afani MD, FACPProfesor Titular
Director Centro de VIHHospital Clínico U. de Chile
Speaker bureau of Gilead, ViiV, BMS, MSD, Janssen, Abbvie
Participating in Boards on HIV
Participation in clinical research: BMS, ViiV, MSD
Sida Chile and Latin American Workshop
Support from ViiV, Gador, BMS, Janssen, MSD, Abbvie
Disclousure
In 2000, 191 countries around the world sign The UnitedNations Millennium Declaration = 8 InternationalMillennium Development Goals were established.
Target 6 = “Have halted by 2015, and begun to reversethe spread of HIV/AIDS”
Millennium Development Goals Report, UNAIDS, 2015
Many advances have been achieved since then andthe pandemic appears to be in retreat.
However only 45% of people with HIV in the
world knows their status.
Resumen de la Epidemia VIH/SIDA al año 2015
Región Número Estimado de
Personas que Viven con VIH
Número Estimado de
Nuevas Infecciones
en 2015
Prevalencia Estimada en
Adultos
Número Estimado de Defunciones por SIDA en
2013Mundo 36,7 millones 2,5 millones 0,8% 1,2 millones
América Latina
1,7 millones 90.000 0,4% 41.000
Chile 39.128 2.555 0,3-0,4% -----
Fuente: Estimaciones Programa Conjunto de Naciones Unidas para el SIDA-ONUSIDA. 2014
Country n centers n patients(06/16 paper)
1 Argentina 6 9.091
2 Chile 11 17.074
3 Colombia 10 17.749
4 Costa Rica 2 2.883
5 Ecuador 5 13.035
6 México 2 18.341
7 Panamá 1 2.468
8 Paraguay 1 844
9 Perú 3 14.693
10 R. Dominicana 2 1.670
11 Venezuela 1 1.692
Total 44 99.540
A Junio 16
Country n centers n patients1 Argentina 14 11.8832 Chile 11 16.8463 Colombia 18 24.7984 Costa Rica 2 2.3065 Ecuador 5 11.4916 Guatemala 1 4.2077 México 4 22.1628 Pánama 2 2.6599 Paraguay 1 0
10 Perú 4 13.32811 Republica Dominicana 2 81112 Venezuela 4 3.682
Total 68 114.173
A Junio 17
> 50 años en control en Latinoamérica
Distribución de casos activos según edad.Centros seleccionados de atención de pacientes
VIH de Latino América. 2013-2014
21,5%> 50 y/o
21,7%
43,9%
22,9%
8,6%
2,6%0,4%
26,1%
36,6%
24,8%
9,1%
3,0%0,4%
36,4%
32,1%
19,2%
9,3%
2,5%0,6%
0%
10%
20%
30%
40%
50%
15-29 30-39 40-49 50-59 60-69 > 70
2001-2005
2006-2010
2011-2015
Distribución por edad casos nuevos en Chile3 quinquenios
0
1000
2000
3000
4000
5000
15-19 20-29 30-39 40-49 >50
1999-2003 2004-2008 2009-2013
125,4% 113,0% 38,5% 94,9% 90,0%
Nuevos casos 1999 – 2013 por edad
-10,0%
10,0%
30,0%
50,0%
70,0%
90,0%
110,0%
15-19 20-29 30-39 40-49 >50
25,9%
5,8% -9,0%
26,5%14,2%
79,0% 101,3%
52,2% 54,0%66,4%
99-03 a 04-08 04-08 a 09-13 99-03 a 09-13
Tasa de aumento por edad
Nuevos casos 2013 – 2015 L Am:aumento en jóvenes
4,8%
15,9%
19,3%
26,5%
18,3%
9,0%
2,9% 0,7%
5,8%
12,4%14,4%
27,7%
19,5%
11,0%
2,9%
0,6%0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
30,0%
35,0%
15-19 20-24 25-29 30-39 40-49 50-59 60-69 >69
Hombres
Mujeres
n= 17.988n= 30 centrosCountries= 82013-2015
40,0%; 32,6%
24,3%22,6%
31,2%36,8%
42,5%42,2%
51,3%
47,2%
25,4%25,7% 26,3% 24,8% 24,2% 26,8%
24,2%
24,2%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
15-19 20-24 25-29 30-39 40-49 50-59 60-69 >69
<200
200-349
350-499
>499
Beltran C, et al. HIV Hepatitis Americas Brazil 2017. P042
Presentación tardía por edad en Latinoamérica
90-90-90: 2020 targets to control HIV-AIDS in Latin America and Caribbean
90 % of people living with HIV
diagnosed
90 % of the diagnosedpeople on ART
90% of those on ART with viral
suppression
Fourth goalReducing late diagnosis (<200 CD4 cells/mm3) below 10%
among newly diagnosed individuals
First Latin American and Caribbean Forum on the Continuum of Care , Mexico, 2014
UNAIDS 90-90-90: HIV Treatment Targets for 2020 with Global Estimates (2014)
Ref: The Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014; JC2684 (Numbers as of March 2015) How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015.
Target 1: 90% of HIV+ people diagnosed
Target 2: 90% of diagnosed people on ART
Target 3:90% of people on ART with HIV RNA suppression
90%81%
73%
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed On ART Viral Suppression
36.9million 33.2
million 29.5million 26.9
million
53%41%
32%*
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed On ART Viral Suppression <1000(ITT)*
36.9million
19.8million 15.0
million 11.6*million
Global Estimates (2014-15) vs the Gap to reach 90-90-90 Targets
Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS RESPONSE July 2015. * Average viral suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review." Bulletin of the World Health Organization 91.5 (2013): 377-385.
Breakpoint 1:13.4 million
Undiagnosed Breakpoint 2: 14.9 million not treated
Breakpoint 3: 15.3 millionNot Virally Supressed
Target 1 versus Target 2:Rates of diagnosis and those diagnosed on
treatment, by country
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Perc
ent o
f dia
gnos
ed p
eopl
e on
ART
Georgia
NetherlandsAverage of
30* Sub-Saharan African countries
Estonia
USA
BrazilBritish Columbia
(Canada)
France
Russia
Denmark
U.KingdomAustralia
Switzerland
UNAIDS 90-90-90 Target 1
Ukraine
Colombia
Cuba
Kyrgyzstan
Vietnam
Rwanda
UNAIDS 90-90-90 Target 2
Percentage of all HIV + people diagnosed*30 countries with data on GAPRP and DHS data, 2008 - 2014 (How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 lessons of hope from the AIDS response July 2015
Cascade of HIV care – Switzerland 2012
81% 80% 79%71% 68%
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed Linked to care Retained in Care On ART Viral Supression <200copies/ml
12,700 12,300
10,70011,200
15,700
12,600
Ref: Kohler P, Schmidt JA, Ledergerber B, Vernazza LP. Estimates of HIV prevalence, proportion of diagnosed patients and quality of treatment in Switzerland. 2014.
Breakpoint 1
Breakpoint 2
Cascade of HIV care – Russia 2013
Ref: Pokrovskaya, A., et al The cascade of HIV care in Russia, 2011–2013. Journal of the International AIDS Society 2014;17(4). http://www ncbi nlm nih gov/pmc/articles/PMC4224814/pdf/JIAS 17 19506 pdf
49%
38% 35%
12% 9%
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed Linked to care Retained in Care On ART <1000 copiesUndetectable HIV RNA
1,363,330
515,403481,783
156,858 127,054
668,032
Breakpoint 1
Breakpoint 2
Breakpoint 3
78% 78%72% 70% 70% 68% 67% 66% 64% 63% 62%
59% 58%54% 53% 52% 52% 52% 51% 50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Prop
ortio
n of
peo
ple
livin
g w
ith H
IV
with
vira
l sup
pres
sion
Países con reportes de más del 50% de supresión virológica (2010-2016)
73%
Kindly provided by Dr. I. Prudente
Sweden the first country to achieve UNAIDS/WHO 90-90-90 targetMichael Carter Published: 14 September 2016
Sweden has become the first country to achieve the UNAIDS/World Health Organization (WHO) 90-90-90 target, research published in HIV Medicine. At the end of 2015, 90% of HIV cases in Sweden were diagnosed, 99.8% of people were linked to care and 95% of people taking ARV for at least 6 months had a viral load below 50 copies/ml.
“We believe that Sweden is the first country to achieve the UNAIDS/WHO 90-90-90 goal,” comment the investigators.
Elementos de Análisis
• Se reconoce un país en el mundo que cumple la meta OMS 90-90-90, con un 73% de personas VIH+ con CV indetectable.
• Gran disparidad y heterogeneidad entre países y dentro de un mismo país.
• Todos los países de Europa Occidental han logrado supresiónviral por sobre >50% de personas VIH+
• Diagnóstico constituye el principal breakpoint globalmente
UNAIDS 2014
Características en Latinoamérica
Heterogénea
60% hombres
Epidemias concentradas en varios países(HSH=15%–20%,mujeres transgénero=16%-32%).
35-40% diagnóstico tardío
UNAIDS report on the global AIDS epidemic 2013. UNAIDS. The Gap Report. No one left behind. 2014.Crabtree-Ramirez B et al. PloS One 2011;6:e20272.
Source: UNAIDS special analysis, 2016
1 2015 measure derived from data reported by 15 countries, which accounted for 76% of people living with HIV in the region. 2 2015 measure derived from data reported by 21 countries. Regionally, 77% of all people on antiretroviral therapy were
reported to have received a viral load test during the reporting period.
Porcentaje de PVV que conoce su diagnostico
Porcentaje de PVV en tratamiento ARV
Porcentaje de PVV con carga viral indetectable
Progreso hacía las metas 90 90 90, América Latina y el Caribe, 2015
Kindly provided by Dr. G. Ravasi
0102030405060708090
100
VIH (+) Dgtco Atendidos En TAR < LDE
100%
69%
54%58%49%
41.681 diagnosticados 34.690 vinculados a atención32.788 en TAR29.628 suprimidos
90 90 90 en Chile 2017A diciembre 2016
Casos confirmados oficialesChile, 2010 - 2015.
BOLETÍN VIGILANCIA DE LABORATORIOVOL. 6, NO. 11, NOVIEMBRE 2016
Cuáles son nuestros objetivos de diagnóstico hoy?
Programa que identifique a la mayor cantidad de personas en estadíos tempranos de la infección y que los vincule con servicios de salud y tratamiento.
Los países necesitan determinar cuál es su mejor estrategia, identificando los servicios de testeo costo-efectivos de mayor alcance a sus poblaciones de riesgo.
Tratamiento antirretroviral en Latinoamérica (2000-2016)
682259
805212
958711
> 1M
42
48
5659
6
1819
6
0
10
20
30
40
50
60
70
80
90
100
0
200.000
400.000
600.000
800.000
1.000.000
1.200.000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Total en TAR Cobertura TAR (total PVV) incremento % (año anterior)
Fuente: ONUSIDA GAM (2001-2017). 2016 datos preliminares.Nota: no incluye datos de Cuba y Republica Dominicana.
N. P
erso
nas
en T
AR
Porc
entu
al (%
)
Kindly provided by Dr. G. Ravasi
87,4%
89,6%
90,0%
91,1%
96,1%
97,5%
88,6%
96,1%
94,8%
88,3%
50%
60%
70%
80%
90%
100%
110%
120%
Arge
ntin
a
Chile
Colo
mbi
a
Cost
a-Ri
ca
Ecua
dor
Mex
ico
Pana
ma
Peru
Rep.
-Dom
.
Vene
zuel
a
% de pacientes en TAR en Latinoamérica
N= 58,280 patients
Unpublished data from the Latin American Workshop Study Group
Results: ART initiation during 1st year follow up
− 74.6 % of 5,681 pts linked to care during 2013-4 started ART during the 1st year.− Significant heterogeneity within countries was observed.− Argentina, México and Dominican Rep. showed the highest rates of ART initiation
(over 90%) while the other countries had ART initiation rates between 60 and 75%.
Figure 2. Percentage of admitted patients that started ART at the first year of follow up, by country
N patients = 5,681N centres = 22N countries = 7
97 96 9591 89 87 84 84 82 81 80 78 78 77 77 77 75 74
0
10
20
30
40
50
60
70
80
90
100
Retención en TAR a 12 meses, Latinoamérica (2016)
% d
e pe
rson
as
Fuente: ONUSIDA, GAM 2017. Datos preliminares
% retención en TAR (12 meses)
Cascada de atención en Latinoamérica
2,000,000 > 1 M
55%
2015 - 2016
41%
75%
Testeo
VinculaciónInicio de TARRetención en TAR
91%
84% 82%77%
71% 70% 69%
61%58% 57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Brazil Mexico El Salvador Honduras Bolivia Colombia Paraguay DominicanRepublic
(the)
Cuba Nicaragua
Carga viral suprimida en personas en TAR, Latinoamérica (2016)
% d
e pe
rson
as e
n TA
R
Fuente: ONUSIDA, GAM 2017. Datos preliminares
Distribución por backbone
39,7%
25,2%
32,8%
1,8%
0%
10%
20%
30%
40%
50%
60%
TDF-xTC ABC-3TC ZDV-3TC Other
Backbone
N patients = 6,007Centres 25; Countries 8
• 32,8% of patients initiating first ART with ZDV containing regimens• TDF use in first line regimens ranges from less 25% to more than 90%
Distribución por 3a droga
• EFV is the preferred 3rd drug followed by PI/r.• Differences in EFV use observed among countries (40 to 90%)• Very low rates of Raltegravir use as first line ARV in Latin America
62,0%
28,7%
4,1% 4,5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
TDF-xTC-EFV/2NRT-EFV
2NRTI/ATVr -2NRTI/LPVr
2NRTI/RAL 2NRTI/Other3th Drug
N patients = 6,410N centres = 28N countries = 7
• De acuerdo a ONUSIDA, 75% de personas diagnosticadas y 55% en TAR
• A pesar de la heterogeneidad en las guías locales para iniciode TAR, cerca del 90% de los pacientes en control está en terapia (75% inició durante el primer año)
• Tasas de retención adecuadas reportadas en la región >80%• Supresión virológica cerca del 90% a 1 año aún con < 50
copias/ml• El aumento en los recursos para cuidados del VIH son el
desafío de la implementación meta sanitaria OMS 909090
En Latinoamérica
INI TDF/FTC + RAL (TAF) TAF/FTC + RAL TDF/FTC + RAL
TDF/FTC/EVG/c (TAF) TAF/FTC/EVG/c TDF/FTC/EVG/c
TDF/FTC + DTG (TAF) TAF/FTC + DTG TDF/FTC + DTG
ABC/3TC/DTG ABC/3TC/DTG ABC/3TC/DTG
bPI TDF/FTC + DRV/ r (TAF)
TDF/FTC + DRV/ r
NNRTI TDF/FTC/RPV TDF+FTC(3TC)+EFV
Esquemas Recomendados de Inicio a 2017
Country Backbone 3rd drug
ARGENTINA 2016 TDF/3TC or FTC EFV; ATV/r, DRV/rUnder evaluation RAL, EVG, DTG
BRAZIL 2016 ABC/3TCTDF/3TC
EFVDTG, RAL
CHILE 2013AZT/3TCABC/3TC
TDF/FTC or 3TC
EFV; ATV/r, LPV/r, DRV/rRAL
Under evaluation EVG y DTG
COLOMBIA 2016 TDF/FTCABC/3TC
EFV; ATV/r, DRV/rRAL
ECUADOR TDF/FTC EFV
MEXICO 2016 TDF/FTCABC/3TC
EFV; ATV/rRAL
PERUAZT/3TCABC/3TC
TDF/FTC or 3TCEFV
URUGUAY 2014 AZT/3TCUnder evaluation TDF/FTC y ABC/3TC
EFV; LPV/r, ATV/rUnder evaluation DTG
VENEZUELA 2014 TDF/FTC EFVATV/r
Kindly provided by Dra. I. Cassetti (modified)
Guías de Tratamiento Antirretroviral en Latinoamérica
Estándares Latinoamericanos de Diagnóstico, Atención y
TratamientoLANZAMIENTO API Panamá Mayo
2017
Escenario 1ª Línea Alternativa No recomendado
Recom. general(TDF o TAF)/FTC o
ABC/3TC + INIs o EFV o RPV o ATV/r o DRV/r
AZT, ddi, d4T, NVP
Presentacióntardía
EFV, DTG, RAL, EVG/c/TDF/FTC DRV/r Otros IP/r
Embarazo ABC/3TC o TDF/FTC ó 3TC + ATV/r o DRV/r o RAL
AZT/3TC + LPV/r o EFV o RPV
Mujer TDF/ FTC+EVG/c, ABC/3TC+DTG
ATV/r o ATV/c; DRV/r o DRV/c EFV
> 50 años INI, ATV/r, DRV/r, RPV EFV
Coinfección TB TDF/FTC o ABC/3TC + EFV o RAL
Coinfección HepB
TDF/FTC, TDF/3TC o TAF/FTC NVP
Coinfección HepC
RAL ó DTG NVP
Escenario 1ª Línea Alternativa No recomendado
Enfermedadrenal
ABC + 3TC, RAL DTG, DRV/r TDF y coformulacionesfijas; LPV/r, ATV
Riesgo CV alto TDF/FTC + RAL o DTG o RPV ABC, EVG/Cobi, IP/r
Dislipidemias RPV/TDF/FTC o RAL o DTG EFV, IP/r, coform Cobi
Alter.neurocogn.
Incierto: INIs, DRV/r, ABC/3TC? EFV, RPV
Cáncer Individualizar (DDI, EfAdv, etc.)