HIV TREATMENT AS PREVENTION THE KEY TO AN AIDS-FREE GENERATION

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1 HIV TREATMENT AS PREVENTION THE KEY TO AN AIDS-FREE GENERATION Adeeba Kamarulzaman Professor of Medicine University of Malaya Executive Council Member International AIDS Society

2 Since the beginning of the epidemic 70 million infections 35 million deaths

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4 Phases of HIV Epidemic Devastation Discovery End of AIDS AIDS 1983 HIV 1983 WHO surveillance 1983 Denver Principles ,000 PLHIV No treatment (Tx) 1985 HIV test 1987 AZT 1987 WHO GPA 1987 TASO Uganda 1985 Reagan mentions AIDS 1986 AIDS Quilt 1986 ACT-UP 1985 Nearly million PLHIV No treatment 1992 AIDS #1 killer US men years old 1993 US Office of National AIDS Policy 1994 AZT to prevent MTCT 1990 Millions PLHIV No treatment 1995 Protease inhibitor 1996 Vancouver triple therapy 1996 US home HIV test 1997 AIDS deaths decline 40% in US 1998 TAC South Africa M PLHIV No Tx 2001 Special UN Session global emergency 2002 Leading cause of death 2002 Global Fund established 2003 PEPFAR 2003 WHO 3x M PLHIV 1M (3%) Tx Africa 50,000 (2%) st generic ARVs 2005 Circumcision RCTs 2006 TasP proposed as HIV control strategy 2008 Swiss statement 2009 Attia metaanalysis ART prevents transmission 2009 WHO proposes using treatment to eliminate HIV M PLHIV 2M (5%) Tx 2011 HPTN 052 proves ART blocks transmission 2012 PrEP approved in US 2010 UNAIDS Treatment 2.0 with treatment as prevention 2014 UNAIDS M targets PLHIV 7.5M (23%) treatment 2015 Fast Track Cities with 60+ cities 2015 STAR and TEMPRANO 2015 HealthGap access to treatment is human right M (49%)people on treatment 2016 Cumulative 39 million AIDS deaths M PLHIV 16M (44%) Tx reached targets affirmed M PLHIV 27 (81%) Tx Policy Hit early, hit hard. Almost no access to treatment in low and middle income countries 2003 WHO CD4 < WHO CD4 < US Treat All 2013 WHOCD4 < WHO Irrespective CD4 Granich Lancet 2017

5 Four Prevention Opportunities Cohen et al, JCI, 2008 Cohen IAS 2008 UNEXPOSED EXPOSED EXPOSED INFECTED (precoital/coital) (postcoital) Behavioral, Structural Vaccines ART PrEP Microbicides Vaccines ART PEP Treatment Of HIV Reduced Infectivity Harm Reduction Circumcision Condoms YEARS HOURS 72h YEARS

6 HIV/AIDS before ART

7 Antiretroviral Therapy works: Treatment for treatment Prevents disease progression Restores immune health Early treatment: Reduced death Reduced cancer Reduced tuberculosis

8 Decline in HIV incidence and mortality over time People dying from AIDS-related causes globally People newly infected with HIV/AIDS globally Source: UNAIDS/WHO estimates.

9 Annual number of new HIV infections Eastern and southern Africa (29%) Asia and the Pacific (13%) Western and central Africa (9%) W & Central Europe and N America (9%) Eastern Europe and central Asia (60%)

10 M living with HIV 1M deaths 1.8M new infections 5000 new infections per day

11 Antiretroviral Therapy works: Prevention Post-exposure prophylaxis (PEP) Prevention of vertical transmission (PMTCT)

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14 TREATMENT IS PREVENTION

15 The OPPOSITES ATTRACT Study (2017)

16 U=U Undetectable Equals Untransmittable

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18 ENDING AIDS TARGET BY 2030 UNAIDS new Global Direction

19 PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently.

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21 Number of people living with HIV on antiretroviral therapy, global, target within the 2011 United Nations Political Declaration on HIV and AIDS Sources: Global AIDS Response Progress Reporting (GARPR) 2016; UNAIDS 2016 estimates.

22 Package of Interventions 22 Outreach Identification Peer lead Information & Education Support Prevention Information & education Counselling Testing Condom promotion PEP PREP STI screening TB screening Support Adherence Trauma counselling Creative spaces Support groups Human rights protection Treatment Test & Treat ART Viral loads Opportunistic infections STI treatment Linkage to care (second line)

23 and The HIV Care Continuum Diagnosed PLHIV Diagnosed PLHIV on ART PLHIV on ART Virally Suppressed Targets 90% 90% 90% Diagnosed PLHIV PLHIV on ART PLHIV Virally Suppressed HIV Care Continuum 90% 81% 73%

24 Program Interventions that address the HIV care CONTINUUM and NHAS targets Prevent new infections HIV diagnosis Link to care Retain in care Treat Suppress viral load Prevent illness and AIDS deaths HUMAN RIGHTS

25 J Justman, CROI2017 :not too ambitious, but a really good start

26 Proportion of people living with HIV diagnosed Top 21 countries reporting more than 84% of people living with diagnosed HIV ( ) 100% 98% 95% 90% 85% 92% 91% 90% 90% 89% 88% 88% 87% 87% 87% 87% 87% 86% 86% 86% 86% 85% 84% 84% 84% 80% 75% 90 % 76 countries with complete care continua

27 Proportion of people living with HIV on ART Top 21 countries reporting more than 64% of people living with HIV on ART ( ) 100% 90% 86% 85% 83% 80% 77% 75% 75% 75% 75% 75% 75% 74% 70% 72% 72% 72% 71% 71% 70% 70% 66% 64% 64% 60% 50% 40% 81 % 76 countries with complete care continua

28 Top 20 countries reporting more than 53% of people living with HIV with viral suppression ( ) Proportion of people living with HIV with viral suppression 100% 90% 80% 80% 78% 78% 70% 72% 72% 70% 70% 68% 67% 67% 66% 64% 63% 62% 62% 60% 59% 60% 50% 57% 54% 53% 40% 30% 73 % 76 countries with complete care continua

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30 CAMBODIA IS ON TRACK TO ACHIEVE THE TARGETS. CAMBODIA S RESPONSE TO AIDS BEGAN IN THE EARLY 1990S, WHEN THE COUNTRY FACED A GENERALIZED, FAST-GROWING EPIDEMIC. TODAY, WE ARE FOCUSING ON PRIORITY POPULATIONS AND AIM TO ELIMINATE NEW HIV INFECTIONS BY MAM BUN HENG MINISTER OF HEALTH, CAMBODIA

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32 HIV & AIDS Epidemic in Malaysia Comparison of New HIV Infections between Injecting Drug Users (IDU) & Sexual Transmission ( ) Source: HIV/STI Sector, Division of Disease Control, Ministry of Health Malaysia

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34 FHDA PG FHDA PG & KD SAHABAT DIC Pahang WAKE KLASS KL Ikhlas Insaf Murni PAMT KL & N9 KLASS Sel DIC Pahang ILZ ILZ ILZ PWID SW MSM Global Fund Funded Projects ( ): Projects, 52 Government Clinics - PWID, SW & MSM Program.

35 Online Outreach Social Network Community Workshop Non reactive Result HIV Anonymous Screening and STI Testing Reactive Result Negative Result Confirmatory Testing Positive Result Treatment & Care Continuum of Care using an innovative, client-focused community case management approach

36 Case Management Flow Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Case workers are resourced to: Find and map KP Assist and accompany them to testing Assist and accompany them to ART Assist KPs to remain adherent to ART to achieve viral load suppression Case Management

37 Case Management All KPs January December KP reached 5461 (51%) underwent HIV test 467 (8.5%) KPs tested HIV+ 131 (28%) KPs on HAART

38 Case Management - PWID January December PWID reached 2346 (50%) underwent HIV test 104 (4.4%) PWID tested HIV+ 27 (25%) PWID on HAART

39 Case Management SW/TG January December SW/TG reached 1459 (42%) underwent HIV test 66 (4.5%) SW/TG tested HIV+ 22 (33%) SW/TG on HAART

40 Case Management - MSM January December MSM reached 1656 (67%) underwent HIV test 297 (18%) MSM tested HIV+ 82 (28%) MSM on HAART

41 What we have learned so far Each KP has different approach MSMs became visible and reachable through online Apps, SW/TG and PWID still venue based approach Changes in Trend Drug use trend shifting from Injecting to noninjecting (poly-drugs), SWs becoming more mobile and going hidden using online sex work. Treatment as the focus Services are more personalised focusing on treatment reducing lost to follow-up. The need for continuous and structured support group sessions Friendly services as a branding Friendly clinics becomes more popular among KPs because spread byword of mouth among KP networks Challenges - Saturated number of clients for PWIDs and SW, difficult to reach sub-group of MSM who use drugs (ChemSex), Legal barriers for PWID, SW and TG groups.

42 Addressing structural, legal, and social barriers drug laws intended to protect have instead contributed to disease transmission, discrimination, lethal violence, and forced displacement, and have undermined people's right to health

43 Mean Score The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia P< P< Medical Students (N=486) Dental Students (N=658) P< P=0.001 P=0.001 P=0.001 P=NS 32.1 General Patients HIV+ Patients PWID Patients MSM Patients Jin et al, AIDS Care 2014

44 SURVEY OF FACTORS ASSOCIATED WITH INTENT TO DISCRIMINATE AGAINST PEOPLE LIVING WITH HIV/AIDS (PLWHA) AMONGST HEALTHCARE PROVIDERS IN MALAYSIA TEE YING CHEW, ADEEBAKAMARULZAMAN, JEFFREY A.WICKERSHAM

45 DISCUSSION 1) Discrimination intent among healthcare providers appears to be lower compared to medical and dental students. - More contact, exposure, and experiences - Higher knowledge about HIV/AIDS - Professional code of conduct 2) Stigma-related constructs are the main factors that contribute to discrimination intent toward PLWHA. more negative feelings toward PLWHA, greater internalized shame, greater fear, greater stereotype and greater disagreement on PLWHA deserve good care hold greater discrimination intent.

46 DISCUSSION 3) Surgical based specialties are more likely to held discrimination intent compare to non-surgical based practitioners. - Perceived higher risk during surgical procedures - Lack of regular clinical contact with PLWHA - Lack of HIV-related training - Lack of knowledge about the disease 4) Prejudice subscale was not correlated with discrimination intent - Knowledge and experience - professional code of conduct, therefore, despite they exhibit prejudice attitude but they do not exhibit discrimination intent toward PLWHA

47 CONCLUSION Antiretroviral therapy works It dramatically reduces epidemic burden and new infections Scaling up of HIV responses is possible It has already been achieved in some nations Ending epidemic AIDS is entirely possible BUT It requires commitment, dedication and imagination

48 Dealing effectively with HIV will require our communities and societies to break down longstanding prejudice, hatred, and ignorance, Only when scientific advances are matched by social and cultural progress can this epidemic truly be contained. Justice Edwin Cameron

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