Biomedical Prevention in HIV

Transcription

1 Biomedical Prevention in HIV CHART - CCAS-CDC 3 RD Joint Meeting Montego Bay, Jamaica August 21-26,2011 Presented by Tina Hylton-Kong, ERTU-CHART Some Slides from Impact of ART on HIV Transmission Wafaa El-Sadr, MD, MPH, ICAP- Columbia University

2 Biomedical Prevention: Overview Role of biomedical prevention List biomedical prevention interventions Review some evidence on effectiveness of these methods Discuss issues on application in the Caribbean region

3 Leadership & scaling up of treatment/prevention efforts Combination Prevention Behavioral Change Biomedical Strategies Highly Active HIV Prevention TREATMENT/ ARV/STI/ ANTIVIRAL Social Justice and Human Rights Community involvement

4 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 & Behavioral Circumcision Condoms YEARS HOURS 72h YEARS

5 Exposure Risks (average, per episode, involving HIV-infected source patient) Percutaneous (blood) 0.3% Mucocutaneous (blood) 0.09% Receptive anal intercourse 1% Insertive anal intercourse 0.06% Receptive vaginal intercourse % Insertive vaginal intercourse % Receptive oral (male) 0.06% Female-female orogenital 4 case reports IDU needle sharing 0.67% Vertical (no prophylaxis) 24%

6 Biomedical Prevention methods Blood Safety HIV free, voluntary donors etc Counselling and Testing Risk reduction in HIV neg and HIV pos STI control (as a public health intervention) Likely important but research results depends on the epidemic context and approach assessed

7 HIV vaccine Biomedical Prevention Intensive efforts >20yrs no vaccine of moderate effectiveness..yet Microbicides Topical ARV preparations and others some failures but research ongoing, challenges such as difficulty with product adherence and possibility of sexual disinhibition* *Nancy Padian et al Lancet Vol 372 Issue 9638 pgs

8 Microbicide trial using ARV Caprisa 004 KZN, South Africa CAPRISA 004 study found a 39% lower HIV infection rate in women using 1% Tenofovir gel Tenofovir gel provided 51% protection against herpes simplex virus type 2 or HSV-2

9 Biomedical Prevention methods Condoms If used correctly and consistently- very effective (numerous observational studies) Male circumcision Shown to be protective against acquisition among men (3 RCTs)

10 HIV Seroincidence (%) Kisumu Study: Circumcision Remains Protective Against HIV Acquisition Kisumu, Kenya trial: extended follow-up of prospective, randomized, controlled trial (N = 1491) Cumulative risk of HIV infection 64% lower in circumcision vs control at 42 months Control Circumcision 7.4% 2.6% Months Bailey RC, et al. IAC Abstract THAC0501.

11 Biomedical Prevention methods ARV for PMTCT Used in both mothers and infants >= 95% success ARV for PEP Used following exposure to a HIV after exposures that include percutaneous (needlestick), splash, bite, sexual ARV for PrEP Used following exposure to a HIV before exposures

12 PMTCT in Jamaica Goal: To reduce perinatal transmission of HIV from over 29% to below 5% through provision of universal access to quality PMTCT care and support services. Objectives: To test 100% of all antenatal clients for HIV To ensure that all HIV positive pregnant women receive ARVs to reduce the risk of HIV transmission. To ensure that all HIV-exposed infants receive a prophylactic course of antiretroviral medication. To ensure the availability of infant formula for all HIV-exposed infants, for at least the first 6 months. To ensure follow-up and HIV diagnosis status of all HIV-exposed infants.

13 Post-Exposure Prophylaxis: Core Principles Evidence is limited Balancing of risks vs benefits Timing: the sooner the better, but interval beyond which there is no benefit is unclear

14 Recommended HIV Post-exposure Prophylaxis Jamaica Guidelines Regimens Basic two-drug regimen AZT/3TC or TDF/ FTC Expanded three-drug regimen AZT/3TC or TDF/ FTC plus LPV/r or IDV/r NB. Standard doses are to be used. For clients 12 years or younger dose as per body weight Expanded three-drug regimen to be offered for sexual assault

15 Pre Exposure Prophylaxis trial IPrex 11 sites in 6 countries (Peru, Brazil, Ecuador,United States, South Africa, Thailand) Men who have sex with men Truvada (Tenofovir and Emtricitabine) based oral PrEP 44% lower infection rate in the control group and 75 % infection rate in the placebo arm

16 Biomedical Prevention methods Treatment as Prevention (TasP) or HAART as treatment and as prevention...

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19 HPTN 052 The study is stopped 4 years ahead of schedule 1763 sero-discordant couples 28 new infections 27 were in the untreated group 96% reduction in transmission in the treated group 17 cases of extrapulmonary TB in the non-treated group and 3 cases in the group receiving early treatment (above 250 CD4 cells) Evidence that treating earlier prevents transmission AND is better for patients

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22 Making the best of available evidence HAART for PMTCT HAART in discordant couples Male circumcision (MC) Pre Exposure Prophylaxis (PrEP) STI treatment Male condom* Female condom* Abstinence* Reducing # of sex partners (absolute and concurrent)* Postponing sexual debut * Strong evidence Weak evidence *No HIV trial evidence: biological plausibility, laboratory data and evidence from observational studies

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27 Integrating Treatment and Prevention Increased VCT with linkage to care Scale-up ARV use starting at CD4 < 350 (maybe higher?) Provide support services: rights protection, adherence, treatment literacy, etc Increased opportunities for other prevention interventions for both HIV+ and HIV-: behavior change, condoms, harm reduction, circumcision, vertical transmission, microbicides

28 Responsibility of Health Providers Treat patient with AWE : Avoid using latex gloves if no blood or body fluids are involved, avoid disgusted non-verbal expressions, behavior that communicates the client is different Welcome all clients with warmth and a smile Equal treatment for all patients, regardless of diagnosis, sexual orientation, age, gender, etc

29 Prevention for Health Providers What preventive measures are used at work? What preventive measures are used at home? (Unprotected sex may be much riskier than your work!!!)