Washington D.C., USA, 22-27 July 2012www.aids2012.org

Treatment as Prevention: It is complex: Let us work on it

Kenneth H. Mayer

Fenway Health

Beth Israel Deaconess Hospital

Harvard Medical School

Boston, Mass

July 23rd, 2012 Session Room 2

Is Treatment as Prevention Utopian?

Percentage of women and men who received an HIV test and test results in last 12 months, 2003–2010 (WHO/UNAIDS)

Most PLHIV are unaware that they are infected Successful TasP requires massive ↑Testing

Still a long way to go to reach 15 million on ART, let alone treating everyone

3 000 000

6 000 000

9 000 000

12 000 000

15 000 000

2003 2004 2005 2006 2007 2008 2009 2010

PLH

IV in

nee

d of

AR

T

Treatment gap

Receiving antiretroviral therapy

Estimated gap: CD4 cell count ≤ 350/mm3 but not on ART

Patients receiving ART 47%3%

WHO, 2011

53%97%

Effective prevention interventions have not been brought to scale

Goal:

~20 million by 2016

Total MCs through 2011:

~1.35 million, 6.5%

of target

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

2008 2009 2010 2011

#

Source: WHO

Male circumcisions performed annually in 14 priority countries in eastern and southern Africa

Major inequities persist in access to treatment and prevention

PROPORTION OF PEOPLE WHO INJECT DRUGS RECEIVING ART IN LOW AND MIDDLE INCOME COUNTRIES IN EECA REGION 2002-10

2002 2005 2006 2010

Number of reporting countries among 26 low- and middle-income countries surveyed

17 21 23 19

HIV cases among people who inject drugs (% among cumulative reported HIV cases with a known transmission route)

46,052 (71%)

221,849(77%)

249,982(77%)

185,565(62%)

People who inject drugs receiving antiretroviral therapy (% among the total reported people receiving ART with a known route of transmission)

130(20%)

4,670(26%)

5,275(26%)

7,646(22%)

Source: Global HIV/AIDS Response. Epidemic update and health sector progress towards Universal Access. Progress Report 2011. WHO/UNAIDS/UNICEF. Table 6.9, p. 137.

Who is Prescribed ART and Who Achieves Viral Suppression in the USA

(MMP)?

Characteristic Prescribed ART % (95% CI)

Virally suppressed % (95% CI)

Race/ethnicity

Non-Hispanic White

92 (90-94) 80 (76-83)

Non-Hispanic Black

86 (83-88)* 64 (60-68)*

Hispanic 89 (86-92) 74 (71-78)

Other 87 (81-94) 69 (63-76)

Sexual risk behavior

MSM 89 (87-91) 76 (72-79)

MSW 91 (88-93) 70 (66-75)

WSM 86 (83-89) 66 (62-70)** P value <0.05 Skarbinski, CROI, 2012

80%

77%

51%89%

77%

MMWR (60), 2011850,000 with HIV do not have virus under control (72%)

Clinical Care System ConsiderationsAddressing the HIV Continuum of Care

Early retention in care (Mugavero et al) The first year in outpatient HIV medical

care is a dynamic, formative & vulnerable time

Poor early retention in care associated with: Delayed / failed antiretroviral therapy (ART)

receipt Delayed time to VL suppression and greater

cumulative HIV burden Increased sexual risk transmission behaviors Increased risk of clinical events & mortality Worse ART adherence, CD4 & VL response

and increased long-term mortality following ART start

Ulett et al. AIDS Pt Care STDS 2009;23, Giordano et al. JAIDS 2003;32, Metsch et al. Clin Infect Dis 2008;47, Mugavero et al. Clin Infect Dis 2009;48, Tripathi et al. AIDS Res Hum Retrovirus 2011;e-pub, Giordano et al. Clin Infect Dis 2007;44

Outcome: 1o HIV provider visit attended w/in:

Case Manageme

nt

Standard of Care

P-value

6 months 78% 60% <0.01

Gardner et al. AIDS 2005;19

Intervention is efficacious, but additional steps needed to promote linkage to care…

12 months 64% 49% <0.01

Linkage to Care: CDC ARTAS

Clinical Care System ConsiderationsLinkage, retention, and effectiveness (USA)

• Linkage to care and preventive services– Only 69% of persons with HIV attend clinic within 12 months

of diagnosis– Case management improves linkage by 32% at cost of $1,200

per person– Interventions focused on adherence increase likelihood of

undetectable viral load by 15%

• Effectiveness depends on coverage during entire cascade from testing to care– Transmission reductions can vary from 15% to 44%

Walensky ClD 2010, Marks AIDS 2010; Crepaz AIDS 2006 11

Looking Ahead:Challenging Times for HIV Prevention

• Picture in the United States especially grim:– Federal deficit ~$1.3 trillion for FY 2011– 5-year freeze on federal discretionary spending– Reductions in HIV prevention by health departments

• ~45,000 state and local public health jobs lost• Staff furloughs, hiring freezes, pay cuts

– Many community organizations closed or struggling

• Similar picture being observed in other Western Industrialized settings, driven by economic downturn

*Total includes HIV and viral hepatitis prevention programs, but majority of funds cut were from HIV

Kaiser Family Foundation; NASTAD; Center on Budget and Policy Priorities

Social Cognitive Model: TasP Needs to Consider Concomitant Issues

Self efficacy

Safer Sex Adherence

Pleasure reduction

Disease prevention

Social Models

Depression, anxiety, mental health problems

Wulfert, Safren, et al., 1999; Journal of Applied Social Psychology

Total HIV-1 Transmission Events: 39

HPTN 052: Lots of “Uncoupled” Transmissions

Linked Transmissions: 28

Unlinked or TBD Transmissions: 11

p < 0.001

Immediate Arm: 1

Delayed Arm: 27

Up to 30% of new infections in couples occur outside the primary relationship (Campbell et al PLoS One

2011; Hughes et al. J Infect Dis 2011)

Source: Tim Hallett, personal communication

A combination of interventions has more impact than the interventions delivered alone

16

Decrease inHIV Transmission

Maintain ViralSuppression

Treat

Enroll in Care

Address concomitant concerns, e.g. depression, substance use,

relationship dynamics

Combination Antiretroviral Prevention

HIV Negative

Test

Interventions to Increase Testing

PositivePrevention

LinkageTo Care

Adherence to ART

ART Initiation

.

Risk Assessment PrEP, Adherence

Counseling

HIV Positive

Thank YouKevin FentonGottfried HirnschallTim HallettSteven SafrenJacek SkarbinskiMichael MugaveroWafaa El-SadrNIAID, NIMH, NIDA, NICHD,

CDC, HRSA, Mass DPH, Gilead

www.thefenwayinstitute.org