Treatment as Prevention:

Transcription

1 Treatment as Prevention: HAART Expansion - A Powerful Strategy to Reduce AIDS Morbidity and Mortality and HIV Incidence Julio Montaner MD, FRCPC, FCCP Director, BC-Centre for Excellence on HIV/AIDS, Providence Health Care Professor of Medicine and Chair, AIDS Research, University of British Columbia President, International AIDS Society WHO, Geneva, Nov 2009 QuickTime and a TIFF (Uncompressed) British Columbia Centre for Excellence in HIV/AIDS

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3 Effect of HAART on HIV Transmission HAART stops HIV replication HIV levels fall to undetectable in blood as well as sexual fluids Sharp reduction in HIV transmission

4 Prevention Strategies - Education - Change in behavoir - Harm reduction - New strategies/technology - Vaccines Existing strategies have failed to contain the global HIV pandemic

5 PERINATAL HIV TRANSMISSION AND MATERNAL VIRAL LOAD: CIHR - CTN CANADIAN PERINATAL HIV SURVEILLANCE PROGRAM (CPHSP)

6 Discordant Couples QuickTime and a S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS Jul 17;23(11):

7 Discordant Couples QuickTime and a Conclusion: Studies of heterosexual discordant couples observed no transmission in patients treated with ART and with viral load below 400 copies/ml, but data were compatible with one transmission per 79 person-years. S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS Jul 17;23(11):

8 QuickTime and a QuickTime and a Anema et al Eur Jour of Inf Dis, 2009

9 QuickTime and a ~ 80% QuickTime and a ~ 20% Anema et al Eur Jour of Inf Dis, 2009

10 QuickTime and a To evaluate the relationship between community plasma HIV RNA and HIV incidence among injection drug users Conducted within Vancouver s DTES Using two concomitant sister cohorts (VIDUS) HIV+ IDUs HIV- IDUs

11 Community plasma HIV RNA levels in a cohort of injection drug users in Vancouver s DTES Whiskers represent 95% confidence intervals. Wood et al, BMJ, May 16, 2009

12 HIV incidence in a cohort of injection drug users in Vancouver s DTES HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals. Wood et al, BMJ, May 16, 2009

13 Community plasma HIV RNA levels and HIV incidence among two parallel cohorts of IDUs HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals. Wood et al, BMJ, May 16, 2009

14 QuickTime and a Wood et al, BMJ, May 16, 2009 QuickTime and a

15 A Formidable Challenge A Unique Opportunity

16 The Power of HAART: Demographic Model 10 Treat 30% HIV prevalence 3 2 Treat all Yea Treat all Treat 30% Number of infections prevented Cost of treatment Treat 30% Treat all Year Treat all Treat 30% Year Montaner et al, Lancet 2006

17 QuickTime and a R Granich, C Gilks, C Dye, K De Cock, B Williams. The Lancet Nov 26th 2008 QuickTime and a

18 New Data Work in Progress Strictly Confidential

19 STOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS* Prospectively Evaluate the Impact of HAART Expansion on AIDS Morbidity and Mortality and HIV Incidence in BC Intervention Primary Endpoint HAART Expansion HIV Incidence within medical guidelines at years 3 to 5 Secondary Endpoints: MORBIDITY AND MORTALITY, CD4 COUNTS, HIV-1-RNA LEVELS, RESISTANCE, ADVERSE EVENTS, SAFETY, ADHERENCE, HOSPITALIZATIONS, RESOURCE UTILIZATION * Supported through a five year Avant Garde Award by the National Institute for Drug Abuse (NIDA) at the NIH

20 HIV Reportable HIV Reportable QuickTime and a Modified from Montaner et al, Lancet, 2006

21 HIV Reportable HIV Reportable QuickTime and a Decrease in HIV new cases attributed to initial roll out of HAART between 1996 and 1999, consistent with that seen in Taiwan (JID, 2005) Modified from Montaner et al, Lancet, 2006

22 HIV Reportable HIV Reportable January 2004 QuickTime and a Decrease in HIV new cases attributed to initial roll out of HAART between 1996 and 1999, consistent with that seen in Taiwan (JID, 2005) Montaner et al, Work in Progress 2009

23 January 2004 QuickTime and a Note that the expansion of HAART here described occurred prior to the new 2008 IAS-USA Guidelines, which were adopted in BC at the end of 2008

24 Jan 2004

25 January 2004

26 25,000 20,000 15,000 10,000 5,000 January Sept. 28, 2009 ³ 50,000 10,000-49, < 500 year 5,000 4,000 3,000 2,000 1, Sept. 28, 2009 Average pvl Highest pvl January 2004 ³ 50,000 10,000-49, < 500 year

27 QuickTime and a QuickTime and a

28 Treatment as Prevention: HAART Expansion - A Powerful Strategy to Reduce AIDS Morbidity and Mortality and HIV Incidence HAART has a substantial added preventive value The magnitude of this effect is not yet fully characterized, and may well vary in different settings Seek and Treat among those who have a medical indication for HAART cannot wait for the above to be resolved Many lives will be saved and much insight will be gained from closely monitoring a more aggressive roll out of HAART Seek and Treat outside the area where treatment is medically indicated remains a research question However, current guidelines, if liberally applied, may leave relatively few outside the treatment envelope Seek and Treat will only be effective as part of a comprehensive Combination Prevention strategy that includes strong HR protection

29 A Statistician s Opinion All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time. Bradford-Hill, A The environment and disease: Association or Causation? President address at January 14 meeting. Proceedings of the Royal Society of Medicine 163 (seriesb):

30 AIDS Nov 27th 2008, The Economist Deploying the drugs used to treat AIDS may be the way to limit its spread Illustration by Peter Schrank QuickTime and a Thank you

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32 Sept. 28, ,000 20,000 15,000 10,000 5,000 0 January 2004 year ³ 50,000 10,000-49, < Sept. 28, 2009 ³ 50,000 10,000-49, < 500 year January 2004

33 5,000 4,000 3,000 2,000 1, Sept. 28, 2009 ³ 50,000 10,000-49, < 500 year Sept. 28, 2009 January 2004 January 2004 Highest pvl year ³ 50,000 10,000-49, < 500

34 Combination prevention Biomedical Interventions Structural Interventions HIV testing and linkage to care HIV prevention Community Interventions Individual and small group behavioral interventions Adapted from T Coates

35 British Columbia Centre for Excellence in HIV/AIDS QuickTime and a Thank You

36 STOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS R Hogg, E Wood, T Kerr, M Tyndall, A Levy, PR Harrigan, V Lima, A Anema, Pedro Cahn, Jose Esparza, Craig Mc Clure ART Guidelines Panel, IAS - USA BC-MoH SPH Foundation Pharmaceutical Industry MSHRF, CIHR, NIDA and NIH H&W, Ottawa Research Staff and Study Participants QuickTime and a TIFF (Uncompressed) British Columbia Centre for Excellence in HIV/AIDS