Treatment as Prevention

Transcription

1 Optimizing the Impact of ART Treatment as Prevention A Made-in-BC Strategy to End the AIDS Pandemic Julio Montaner, OC, OBC, MD Professor of Medicine and Head, Division of AIDS, University of British Columbia Director, BC Centre for Excellence in HIV/AIDS at Providence Health Care UNAIDS Special Advisor on HIV Therapeutics Universidad del Salvador Buenos Aires, Sept 22 nd 2016

2 Introduced HAART Vancouver 1996 One World One Hope Impact of HAART in BC

3 New HIV and Syphilis in BC

4 Julio Montaner, Robert Hogg, Evan Wood, Thomas Kerr et al The Lancet; 2006, 368:

5 Increasing HAART Coverage in BC Pre-HAART HAART TasP January 2004 Summer of 1996 Summer of 2000 # of active participants on HAART in the HIV treatment programme Phase I Phase II Phase III Montaner et al, PLOS One 2014

6 AIDS Mortality AIDS Incidence Pre HAART HAART TasP 2016: Near Normal QoL & LE HAART TasP V Lima, J Nakagawa, R Hoog, J Montaner et al, 2016

7 Vancouver Sun, May 31, 2014

8 New HIV Diagnoses and HAART Use Testing Rates in BC HAART TasP Modified from Montaner et al, PLOS One, Feb

9 Vertical Transmission (VT) ART is 100% effective at preventing VT Over the last 15 years, the widespread use of immediate ART, eliminated vertical transmission in BC

10 Expanding ART Saves Lives and Money (e.g.: South Africa) Granich et al, PLoS ONE 7(2):e30216, Feb 2012

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12 HPTN 052: Effectiveness of Treatment e as Prevention ee 30 RCT of Immediate vs. Delayed ART in Sero Discordant Couples 1, No genetically linked HIV transmissions when index case virologically suppressed on ART 3 Immediate vs. Delayed ART in Sero-discordant Couples Deferred Immediate 0 Sero Conversions 1 Cohen et al. IAS Abst MOAX0102; 2 Cohen et al. N Engl J Med. 2011; 3 Cohen et al. IAS Abst MOAC0101LB.

13 PARTNER Study Overall risk = Zero through condomless sex with a partner on ART (HIV RNA <200 copies/ml Rodger A, et al. JAMA. 2016;316(2): doi: /jama

14 TEMPRANO: Immediate vs Deferred ART ± IPT ility re (%) e Probabi or Sever d Illness umulative of Death IV-Relate C H Mo Probability, % Deferred ART 14.1 Deferred ART + IPT 8.8 Immediate ART 7.4 Immediate ART + IPT Mos From Randomization TEMPRANO ANRS Study Group, N Engl J Med. 2015

15 START: Immediate ART Reduced Risk of Serious Events or Death by 57% 41% 4.1% vs 18%i 1.8% in deferred dvs immediate arms experienced serious AIDS or non-aids related event or death (HR: 0.43; 95% CI: ; P <.001) Cumula ative Perce ent With Ev vent Deferred ART Mo Immediate ART Lundgren J, et al. IAS Abstract MOSY0302. INSIGHT START Study Group. N Engl J Med

16 THE FINAL CHAPTER OF THE AIDS EPIDEMIC

17 An Ambitious Treatment Target to END* the AIDS Pandemic THE FINAL CHAPTER OF THE AIDS EPIDEMIC * Defined as decreasing overall disease burden (M&M&T) by 90% from global 2010 levels

18 An Ambitious Treatment Target to END* the AIDS Pandemic 90% 81% 73% THE FINAL CHAPTER OF THE AIDS EPIDEMIC * Defined as decreasing overall disease burden (M&M&T) by 90% from global 2010 levels

19 Ending AIDS: Reducing new infections and AIDS-related deaths by 90% of 2010 levels Stover et al, GAP Report, UNAIDS, 2014

20 Progress toward the Target in BC as % of Estimated HIV Prevalence V Lima, J Nakagawa, R Hogg et al, in preparation, 2016

21 Progress toward the Target in BC as % of previous step V Lima, J Nakagawa, R Hogg et al, in preparation, 2016

22 D. Havlir: If we could decrease new HIV diagnoses at the same rate seen since 2012, we would get to zero by 2019 BUT We have to reach those not yet reached. Diane Havlir, UN Workshop, Durban, July 2016

23 Correlation between HIV treatment and incidence 1.1% (0.8% 1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage. ce rate rati io p=0.325 p=0.003 p= p=0.013 Inciden ART & HIV incidence: Hlabisa, South Africa 0% 30% 60% ART coverage Tanser et al. Science 2013;339:

24 BOTSWANA S CASCADE 100% [CELLRANGE] 80% Goal: 90% Goal: 81% Goal: 73% 60% 100% 40% 83 3% 72 8% 70 2% 20% 0% HIV positive ii people Diagnosed Currently on ART Suppressed viral lload BCPP Baseline Household Survey UNAIDS Goal Max Essex et al, UN Workshop, Durban, July 2016

25 100% 90% 80% 70% 60% SEARCH: UN TARGET UGANDA AND KENYA 90% target 50% 40% 30% 70% 96% 97% 80% 91% 94% 86% 89% 90% 20% 10% 0% % HIV+ w/ Prior Dx % Prior Dx ever on ART % Ever on ART w/ Supp Baseline Follow Up Year 1 Follow Up Year 2 Petersen, IAC, 2016

26 FY16 Rwanda Expected Cascade % % % # PLHIV # Diagnosed # Linked to care # Current on ART # Virally suppressed PEPFAR Non PEPFAR Population Total Debbie Birx, UN Workshop, Durban, July 2016

27 UN Target: Global Status in 2015 HEALTH GAP, UN Workshop, Durban, July 2016

28 UN Target: Global Status in 2015 By Region HEALTH GAP, UN Workshop, Durban, July 2016

29 New HIV Diagnoses per Year, Canada R Hogg, V Lima, J Nakagawa, et al, in preparation, 2016

30 70000 Number of New Adult (15+) HIV Infections in Kenya by Province ( ) Central Coast Eastern Nairobi North Eastern Nyanza Rift Valley Western Source: UNAIDS, 2016

31 Swaziland s Cascade MALES FEMALES Debbie Birx, UN Workshop, Durban, July 2016

32 100% 80% 60% 40% 20% 0% 20% 40% Percent change in NEW ADULT HIV infections, from 2000 to 2015 Burundi Kenya Uganda Cameroon Swaziland Zambia Nigeria Mozambique Lesotho Zimbabwe Rwanda South Africa Côte d'ivoire Tanzania Botswana Ghana Namibia Malawi DRC 60% 80% 100% Source: UNAIDS, 2016

33 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria & neglected tropical diseases. Combat hepatitis, water-borne diseases & other communicable diseases

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35 International ti HIV/AIDS Assistance, 2002 to 2015

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37 5 th GF Replenishment Conference PM Justin Trudeau announced $785 million over 3 years for the Global Fund a 20% increase in Canada's contributions Montreal, Canada, Sept 16 th 17 th, 2016

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39 Treatment as Prevention Targeted Disease Elimination Health Care Sustainability