CHAI at IAS 2015
In late July Vancouver hosted the 8th annual International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment & Prevention. Over 20 CHAI staff members from around the world presented a wide variety of work at the meeting.
The conference was characterized by a few themes, among them a continued commitment to the ambitious “90-90-90” target: 90 percent of patients living with HIV to know their status, 90 percent of diagnosed patients to be receiving antiretroviral therapy (ART), and 90 percent of patients on ART to have viral suppression. Another dominant theme was the push for expanding access to universal treatment. This was supported by two trials presented (START and Temprano) that provide evidence supporting early initiation of ART regardless of CD4 count. The World Health Organization (WHO) shared its plans to release new ART guidelines by the end of the year that will encourage countries to adopt strategies to provide early treatment for their populations. Leaders from the WHO, UNAIDS, and PEPFAR encouraged countries to begin to plan for expanded access to treatment and not wait for the paper versions of the guidelines to start on this important work.
At the conference, there was also substantial buzz surrounding the need for a dramatic shift towards implementation optimization: finding the best ways for patients and communities to improve access to testing, treatment, and monitoring with the goals of viral suppression, patients living healthier, longer lives, and a reduction in new infections. Additionally, scientists working on vaccines, potential cures, and better biomedical prevention strategies presented their work, lending optimism to the possibility of ending the HIV/AIDS epidemic.
CHAI presented a wide array of work from projects around the world, including:
• CHAI and the Zambian Ministry of Health (MOH) presented a poster that relates to both of these pieces of work and fits a prevailing theme of the conference towards optimizing treatment delivery. The presentation, titled, Congestion in urban HIV treatment clinics in Lusaka, Zambia: an assessment of factors to inform decongestion solutions (Moberley S. et al, TUPED769), discussed a November 2014 assessment of the contributors to busy ART clinics in Lusaka, Zambia. Although Zambia’s national ART guidelines recommend that stable ART patients receive 3-month prescriptions, the assessment found that most stable patients were not actually receiving 3 months of drugs at a time. As a result, patients make frequent visits to the clinic, often only to pick up their medications. This is likely contributing to clinic congestion and patient dissatisfaction, which in turn negatively impacts retention and viral suppression. Using these findings, CHAI and the MOH tailored an intervention using quality improvement officers to troubleshoot challenges and improve compliance to the MOH policy of 3-month ART refills. We were able to conduct this work with support from the UKAID Department for International Development. This facility-level quality improvement work is a precursor to innovative delivery models. Clinicians need a definition of which patients qualify as stable, and facility systems have to be in place with strong record-keeping, planning, and drug forecasting. These systems-level challenges can be addressed and need to be prioritized so that they do not stand in the way of optimizing treatment delivery.
• What does a national response to closing the gap in pediatric and adolescent HIV treatment cost? Zambian costing model for universal pediatric treatment (McCarthy E. et al, WEPED888): This presentation covered collaborative work by members of the Interagency Task Team (IATT) to provide policymakers and planners in Zambia with cost-based evidence to develop a budgetary roadmap that will allow them to expand HIV treatment to universal access among children and adolescents.
• What is the cost of antiretroviral drug durability? (Campbell J. et al. WEPEB371): This CHAI presentation summarized comparative analyses we conducted to look at long-term treatment costs of preferred regimen TDF/3TC/EFV and a hypothetical regimen that is both more expensive and more durable. We measured durability as time spent on first-line treatment, to better understand how much better a more expensive regimen must be in order to offset more expensive costs in first-line treatment.
• Current and Future Uptake of Diagnostics (Katz Z., SUSA13): This presentation focused on the considerations that programs should incorporate when planning for new diagnostics. The technology pipeline for point-of-care (POC) diagnostics is strong and we can anticipate their increasing uptake in the coming years. Using lessons from POC CD4 uptake for other areas is an opportunity that should not be lost. Aspects of the new products also have to be considered, and in particular cost. Mapping patient access across countries is a way to appropriately place products so that on the one hand the product is used enough so that the capital expenditure is justified, and on the other is not placed in a facility that has more need than the product can handle. Overall, integrated systems where new products like POC and existing laboratory products are used together is the most likely and cost effective scenario. In line with this work, CHAI is partnering with UNICEF through UNITAID on a project to accelerate the use of HIV POC diagnostics. The presentation complied CHAI learnings from the first phases of our related work in seven countries in Sub-Saharan Africa. As new products become available, a lot of work is required to appropriately select products that fit country needs, and appropriately place products within a health system to maximize efficiency.