Global HIV Treatment OptimizationSince 2010, Pangaea has been at the forefront of global efforts to improve the quality of HIV treatment – including drugs, delivery systems, and diagnostics – globally for people with HIV, regardless of where they are from. Pangaea’s Treatment Optimization initiative is a partnership of global researchers, health care providers, drug manufacturers, policy makers, funders, and community members from heavily affected regions.
What is HIV treatment optimization?There are three priorities:
1. Better drug regimensTaking stock of the current research and development agenda to answer questions, such as can we make drugs that are easier to take and adhere to? Do we know if they work for pregnant women and children? Who should be doing what, who is going to pay for it and who is going to make sure it happens? When can generic manufacturers plan for scale up? And talk to patients—before spending millions on testing and manufacturing – to make sure the regimens will work for them.
Drug optimization revolves around develop drug regimens that are safe, effective, simple, tolerable, durable, universal and affordable. A key challenge is to bringing the highly effective treatment regimens that are available in the industrialized world to the global South. Treatment optimization strategies to achieve a more appropriate target product profile for heavily affected countries include increasing bioavailability, improving the manufacturing process, sourcing less expensive raw materials, and extending the shelf life. ARVs can also be improved by developing supplies chains, limiting clinic stock-outs, working within communities to ensure treatment is destigmatized and effective, decentralizing treatment programs and policies, and incorporating research into delivery implementation
2. Improved service deliveryThis means decentralizing care and improving supply chain so that remote clinics have the tests and medicines in stock when patients need them and working within communities so the services are welcoming, effective, and consistent. It also means putting into place policies and programs so that previously ‘unskilled’ health workers can provide their clients with critical medicines and care.
Adapting service delivery towards decentralized, integrated, community-centered approaches is critical to achieving universal access. UNAIDS estimates that more than 95% of HIV care and treatment in Africa is based on traditional clinic models and has called for at least 30% of care to be delivered in out-of-clinic, community settings to support the continued rollout of ART and to reduce cost. The optimization of service delivery is based on the model of differentiated care, a framework which provides treatment tailored to the needs of people rather than a one size fits all clinic model. The differentiated care framework articulates the location and frequency of care for people living with HIV (PLHIV) who are sick and those who are well, what services are provided based on need and the cadre of provider, whether that be a physician, nurse, pharmacist or trained PLHIV. It is envisaged that an undetectable viral load will be a key decision-making tool as stable PLHIV increasingly receive care in the communities where they live. As part of its best practice work, Pangaea will map existing patterns of service delivery in selected focus countries using population-based surveys and track how these change over time with projected increase use of differentiated care models.
3. Access to the latest HIV tests and diagnosticsRemote population areas, poor laboratory infrastructure and lack of technical expertise required to diagnose and monitor patients are some of the most important challenges. Without monitoring tools there is a substantially increased risk of adverse medical and public health consequences. The availability of viral load testing – critical to ensuring treatment is still effective – is especially limited.
The optimization of diagnostics comes at a time of change with the prioritization of viral load for monitoring treatment success and failure and the de-emphasizing of CD4 count measurement for treatment monitoring. Going forward, diagnostics optimization entails learning lessons from the use of viral load for the early infant diagnosis and applying successful models of dried blood spot specimen transport to central labs and return the results to clinics. No point-of-care viral load device yet exists and optimization in the space will involve understanding the right mix of point-of-care devices and central laboratory testing. Pangaea will work with partners to monitor the scale-up of viral load testing, especially as it relates to the rollout of differentiated care described below.
Conference on Antiretroviral Drug Optimization (CADO)
The first CADO was held in 2010, organized by the Clinton Health Access Initiative (CHAI), the John Hopkins University School of Medicine, and the Bill & Melinda Gates Foundation. Its goal was to explore strategies for the reduction of antiretroviral drug costs.
Pangaea hosted the second CADO in 2013 to identify an HIV research agenda for resource-limited settings over the next five-to-ten years, review existing compounds in early development, identify potential novel approaches to reinvigorate first- and second-line regimens, and determine the role of new technologies to improve long-term durability and affordability. These two conferences brought together experts from academia, governments, foundations, the pharmaceutical industry, and community activists to develop a global HIV-treatment research agenda for the coming decade focused on better therapies and how to make them accessible to a broader population of people living with HIV.
In 2015, Pangaea convened a smaller meeting of experts at the Vancouver International AIDS Society (IAS) Conference with the Amsterdam Institute for Global Health and Development (AIGHD), CHAI, and IAS, to prioritize actions and make recommendations to optimize the medium-term future of HIV treatment. The meeting was chaired by Pangaea’s Treatment Optimization Co-Chairs, Dr Tsi Tsi Apollo, Deputy Director for HIV/AIDS and STIs in the Zimbabwe Ministry of Health and Child Care and Dr Andrew Kambugu, Head of Department, Research Program at Infectious Diseases Institute (IDI), Makerere University College of Health Sciences, Kampala.
Pangaea and partners will continue to convene CADOs as necessary in the next 5 years to ensure research into better treatment regimens, monitoring and delivery is scaled up to meet the growing need.
To access a copy of the CADO 1 report please use the link below
Please download full copies of the CADO 2 and Vancouver TO meeting reports