Test and Treat:

Michael Saag, MD, FIDSAUniversity of Alabama, BirminghamDirector, Center for AIDS Research

or Halloween?

Is it All Saints Day ?

Updated from Chen, et al, 8th CROI, 2001

8 Year Survival in HAART Era

CD4 Count at HAART Initiation

Median CD4

% CD4 < 200

1996 115 62.8%1997 180 53.8%1998 221 47.8%1999 212 49.3%2000 197 50.1%2001 277 39.5%2002 210 48.8%2003 220 47.2%2004 207 49.1%

Median CD4

% CD4 < 200

2005 278 39.6%2006 300 35.4%2007 296 35.2%2008 310 29.4%

Key Point:

Many (? Most) HIV infected patients in the US don’t know they are infected

• Universal, opt-out testing is needed

Or is it….?

John Phillips: Libertarian “You gotta go where you wanna goDo what you wanna doWith whoever youWanna, wanna do it with….”

Slide 6

When To Start Treatment? –Summary of Current Guidelines

Guidelines symptomsorCD4 <200

CD4 200-350

CD4 >350

IAS-USA:JAMA 2008<www.iasusa.org>

treat treat Therapy should be considered and decision individualized

DHHS:<www.aidsinfo.nih.gov>

treat treat treat*

* Split opinion > 500

symptoms

Slide 7

When To Start Treatment? –Summary of Current Guidelines

Guidelines symptomsorCD4 <200

CD4 200-350

CD4 >350

IAS-USA:JAMA 2008<www.iasusa.org>

TREAT TREAT Therapy should be considered and decision individualized

DHHS:<www.aidsinfo.nih.gov>

TREAT TREAT TREAT*

* Split opinion > 500

symptoms

Slide 8

Cohort Study Results (NA-ACCORD / ART-CC)

Consequences of unchecked viral replication (Inflammation / Harm)

Improved tolerability / convenience of newer ARV regimens

Treatment reduces transmission of HIV Cost Savings

Reasons for Earlier Initiation of Therapy

Slide 9

Relative Time on Treatment…

30 35 40 45 50 55 60 65 70AGE (years)

CD4 650/ul

CD4 500/ul

40 years on Rx

35 years on Rx

5 years

Slide 10

Relative Time on Treatment…

30 35 40 45 50 55 60 65 70AGE (years)

CD4 650/ul

CD4 500/ul

40 years on Rx

35 years on Rx

5 years

HARM?

Slide 11Most New Infections Transmitted by

Persons who Do Not Know Their Status

~25% Unaware

of Infection

~75% Aware

of Infection

account for…

~54% New

Infections

~46% of New

Infections

Source: G. Marks et al. AIDS 2006

Slide 12

Prevention of Transmission

♦ TEST and TREAT – Testing and Linkage to Care (TLC+)

National AIDS Strategy…

ARV Receipt

Retention in Care

OutcomesHIV Dx Linkage

to CareARV

Adherence

Adapted from: Giordano et al. Curr HIV/AIDS Rep 2005;2:177-183, Samet et al. AIDS 2001;15:77-85, Eldred & Malitz. AIDS Pt Care STDs 2007;21:S1-2; Tobias et al. AIDS Pt Care STDs 2007;21:S3-8

Blueprint for HIV Treatment Success

ARV Receipt

Retention in Care

OutcomesHIV Dx Linkage

to CareARV

Adherence

Expanding the spectrum of adherence

25% of HIV-infected individuals in the U.S.

are undiagnosed

20-40% of newly diagnosed pts. fail to

establish care w/in 6 mos.

One-third of pts. w/ known HIV infection are not

engaged in care

Glynn & Rhodes. National HIV Prevention Conference 2005, Abstract 595, Gardner et al. AIDS 2005;19:423-431, Mugavero et al. Clin Infect Dis 2007;45:127-130, Fleming et al. 9th CROI 2002, abstract 11

Mean Annual Total Patient Costs by CD4 Count (cells/ul)

Mean Annual Total Patient Costs by Component

Key Points

• Mortality is much higher when patients are diagnosed late in the course of infection (CD4 < 200 /ul)

• The majority (> 50%) of newly diagnosed patients are diagnosed late (except preg Women)

• Many (? Most) HIV infected patients in the US don’t know they are infected

• Universal, opt-out testing is needed

With more universal testing, a 25 -50% increase in patient volume will occur

Who will take care of these patients?

Provision of medications

• “Every American who needs HIV treatment and care should have access to it”

• “People who are HIV-positive need essential medications”

• “Without the drugs, providing care is difficult to impossible”

PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7

Provision of HIV CARE• “Every American who needs HIV treatment

and care should have access to it”• “People who are HIV-positive need

essential medications”• “Without the drugs, providing care is

difficult to impossible”• “Without qualified HIV care providers and

clinics, HIV drugs mean nothing”

PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7

EDITORIAL COMMENTARY

Which Policy to ADAP-T:Waiting Lists or Waiting Lines?

Michael S. SaagUniversity of Alabama at Birmingham Center forAIDS Research

Clinical Infectious Diseases 2006;43:1365-1367© 2006 by the Infectious Diseases Society of America. All rights reserved.