Think Globally and Locally Ending Epidemic AIDS Benjamin

Think Globally and Locally: Ending Epidemic AIDS Benjamin Young, MD Ph. D International Association of Providers of AIDS Care (IAPAC)

DISCLOSURES • Consultant/Advisory Board – Gilead Sciences, Merck & Co, Vii. V Healthcare • Research Support – Gilead Sciences, Merck & Co, Vii. V Healthcare • Speaker Bureau – Merck & Co

OBJECTIVES • Evaluate the UNAIDS 2020 90 -90 -90 targets • Explain why cities are important laboratories for public health innovation • Relate how implementation of antiretroviral therapy can end epidemic AIDS

HIV/AIDS BEFORE ANTIRETROVIRAL TREATMENT

Global summary of the AIDS epidemic Number of people living with HIV in 2015 People newly infected with HIV in 2015 AIDS deaths in 2015 Source: UNAIDS/WHO estimates. Total 36. 7 million [34. 0 million – 39. 8 Adults million] Women 31. 8 million [30. 1 million – 33. 7 Children (<15 million] years) 16. 0 million [15. 2 million – 16. 9 million] 3. 2 million [2. 9 million – 3. 5 Total million] Adults Children (<15 years) 2. 1 million [1. 9 million – 2. 4 million] 1. 9 million [1. 7 million – 2. 1 Total million] Adults 240 000 [210 000 – 280 000] Children (<15 years) 1. 1 million [940 000 – 1. 3 million] 1. 0 million [1. 2 million – 1. 5 million]

Decline in HIV incidence and mortality over time 3 500 000 People dying from AIDS-related causes globally 3 000 People newly infected with HIV/AIDS globally 2 500 000 2 000 1 500 000 1 000 500 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: UNAIDS/WHO estimates.

5, 600 new HIV infections a day in 2014 § ~2/3 are in Sub-Saharan Africa § ~600 children § ~5, 000 adults, of whom: § 48% are women § 30% are young people

ANTIRETROVIRAL THERAPY WORKS • Well tolerated • Easy to administer – Most are once-daily, many single tablet regimens • Cost-effective – Can be as low as $100200/patient year

ANTIRETROVIRAL THERAPY WORKS: TREATMENT FOR TREATMENT • Prevents disease progression • Restores immune health • Prevents transmission • Early treatment: – Reduced death – Reduced cancer – Reduced tuberculosis

ANTIRETROVIRAL THERAPY WORKS: PREVENTION • Post-exposure prophylaxis (PEP) • Pre-exposure prophylaxis (Pr. EP) • Prevention of vertical transmission (PMTCT)

ANTIRETROVIRAL THERAPY WORKS: U=U Undetectable Equals Untransmittable

Gardner, et al. , Clin Inf Dis 2011

UNAIDS 2014

Number of people newly infected with HIV Source: UNAIDS/WHO estimates. The red shading shows future targets.

Number of people dying from HIV Source: UNAIDS/WHO estimates. The red shading shows future targets.

CITIES

CITIES ARE HOME TO LARGE PROPORTIONS OF PEOPLE LIVING WITH HIV • Liberia – 80% of PLHIV in Monrovia • Jamaica – 64% of PLHIV in Kingston • Peru – 45% of PLHIV in Lima • Cote d’Ivoire – 43% of PLHIV in Abidjan • Argentina – 43% of PLHIV in Buenos Aires • Portugal – 43% of PLHIV in Lisbon • Chile – 37% of PLHIV in Santiago

• Cities are vibrant hubs of economic growth, learning and innovation • Ideal platforms for developing better, fairer societies

We call on major cities to fast-track their AIDS responses by 2020: § § § Frontloading investments and stepping up the pace of service delivery Strengthening and leveraging existing HIV programming for greater impact Scaling up HIV services, especially HIV testing and treatment

FAST-TRACK CITY INITIATIVE TARGETS 90% Of people living with HIV knowing their HIV status 90% Of people who know their HIV status on ART 90% Of people on treatment with suppressed viral load 0% Stigma and discrimination

90 -90 -90 AND THE HIV CARE CONTINUUM Diagnosed PLHIV on ART Diagnosed Virally PLHIV on ART Suppressed HIV Care Continuum 90% 90% Diagnosed PLHIV 90 -90 -90 Targets PLHIV on ART PLHIV Virally Suppressed 90% 81% 73%

INTERNATIONAL TECHNICAL COLLABORATION FTCI provides a platform for thinking and partnering globally and locally to leverage existing programs and resources. • Twinning and technical exchanges • Sharing best practices • Cities conferences and meetings • Scientific literature publications and presentations

FTCI INCLUDES ALL TYPES OF CITIES FROM ALL REGIONS OF THE WORLD

CURRENT KEY FAST-TRACK CITIES

PROGRAM INTERVENTIONS THAT ADDRESS THE HIV CARE CONTINUUM 90 -90 -90 and NHAS targets Prevent new infections HIV diagnosis Link to care Retain in care HUMAN RIGHTS Treat Suppress viral load Prevent illness and AIDS deaths

IMPLEMENTATION PLAN PROGRAMS INTERVENTIONS RESOURCE MOBILIZATION 90 -90 -90 M&E & Zero Discrimination COMMUNICATIONS PROCESS & OVERSIGHT

PROCESS AND OVERSIGHT: • International FTCI process and oversight – IAPAC, UNAIDS, City of Paris and UN-HABITAT • City leadership for local process and oversight – Cities host meetings to convene stakeholders – Review HIV epidemiology and response – Discuss program and resources – Develop measurable targets and action plans – Establish process for implementing and monitoring progress towards FTCI (read local) targets.

MONITORING AND EVALUATION § Establish epidemiology and program baseline – HIV care continuum and 90 -90 -90 – Basic HIV indicators – Program targets § Define success – Paris Declaration – 90 -90 -90 – End of AIDS – Urban HIV Control § Democratization of Data and Data Transparency

DEMOCRATIZATION AND DATA TRANSPARENCY Data Transparency and Accountability - Decrease the time between data generation and reporting in public domain for closer to real-time response - Facilitate globally comparable HIV Care Continuum Indicators - Improve accountability between stakeholders, including community Democratization of Data - Crowd sourcing using i. Monitor+ real time geolocation of data - Use of crowdsourced data for real-time course corrections - Real time programmatic data

WWW. FAST-TRACKCITIES. ORG

Official fast track cities global portal

CITY DASHBOARD FEATURES HIV RESPONSE

POWERFUL MAPPING OF HIV SERVICES

: challenges • Implementation – – Normative guidance Diagnostics Treatment Drug resistance • Finance • Stigma, discrimination, criminalization • Complacency

: not too ambitious, but a really good start

: not too ambitious, but a really good start J Justman, CROI 2017

: not too ambitious, but a really good start

: not too ambitious, but a really good start

ADDITIONAL EFFORTS FOR 2016/17 • Mitigating Stigma and Discrimination in Health Care Settings – Web-Based Human Rights Training and Certification for Healthcare Providers • 4 th 90 – Quality of Life – Survey among PLHIV, particularly KPs, using Qo. L indicators – Quantification of a Qo. L 4 th 90 indicator – Measure and monitor quality of life for Fast-Track Cities • Capacity Building of Health Care Providers – increasing HIV testing coverage and diagnosis – increasing linkage to care and HIV treatment coverage – increasing engagement and retention in HIV care, ART adherence, and viral suppression.

THANK YOU SUMMARY • Antiretroviral therapy works and can dramatically reduce epidemic burden and new infections • UNAIDS’ 2020 targets call for acceleration of HIV testing, care and treatment responses • Cities are hubs of public health innovation and are platforms for developing better, fairer societies • Scaling up of HIV responses is possible and has already been achieved in some municipalities and nations • Ending epidemic AIDS is entirely possible but requires commitment, dedication and imagination. • Dream big. Take risks.

THANK YOU Thank you/Gracias/Merci! IAPAC Sindhu Ravishankar Reuben Granich José M. Zuniga Vipin Yadav and Dure Technologies Bertrand Audoin Mara Nakagawa Harwood Somya Gupta Maggie Dorr Emma Stacey And our partners – • UNAIDS • UN-Habitat • City of Paris

byoung@iapac. org www. IAPAC. org