Treatment as Prevention

Transcription

1 Treatment as Prevention The Key to an AIDS-Free Generation Julio Montaner MD, DSc(hon), FRCPC, FCCP, FRSC, OBC Director, BC-Centre for Excellence in HIV/AIDS, Providence Health Care Professor of Medicine and Head, Division of AIDS, University of British Columbia Past-President, International AIDS Society Summit to End HIV/AIDS in America Las Vegas, Sat Sept 29 th 2012 BRITISH COLUMBIA CENTRE for EXCELLENCE in HIV/AIDS

2 USA - Trends in Annual Rates of Death Ages 25 to 44 Deaths per 100,000 Population Year Unintentional injury Cancer Heart disease Suicide HIV infection Homicide Chronic liver disease Stroke Diabetes

3 Vancouver 1996 One World One Hope

4 Impact of HAART in BC-CfE 140 Death Rate per Life Expectancy at age Modified from Hogg et al, Lancet. 2009

5 New HIV and Syphilis in BC BC-CDC, 2005

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8 HIV infections per 1000 population Infections (millions) 10 9 Treat 30% HIV prevalence Treat all Hypothetical Demographic Model Year Treat all Treat 30% Number of infections prevented Year Cost (billions) Cost of treatment Treat 30% Treat all Year Treat all Treat 30% Montaner et al. Lancet, 2006

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10 HAART Outcomes among Injection Drug Users The Vancouver Experience

11 Wood et al, BMJ, 2009 Whiskers represent 95% confidence intervals.

12 Wood et al, BMJ, 2009 Whiskers represent 95% confidence intervals.

13 TasP in Serodiscordant Couples

14 HPTN 052: Immediate vs Delayed ART in Sero-discordant Couples % Deferred HR = 96.3% reduction in transmission No difference whether index pt was M or F Immediate Cohen MS, et al. IAS Abst MOAX0102 Cohen MS, et al. N Engl J Med. 2011

15 HPTN 052: Immediate vs Delayed ART in Sero-discordant Couples % Extra-Pulmonary TB Deferred : Immediate : 17 cases 3 cases 84% Reduction Deferred Immediate M Cohen et al, IAS-Rome, July 2011 M Cohen, NEJM 2011

16 Increasing HAART Coverage within Evolving Medical Guidelines in the province of British Columbia

17 Increasing HAART Coverage within Evolving Guidelines in BC N = 7492 by the end of 2011 Summer of 1996 Summer of 2000 January 2004 Phase I Phase II Phase III Year Montaner et al, Lancet, 2010

18 BC: All Cause Mortality (#) Frequency Years Montaner et al, TasP Workshop, April 2012

19 Montaner et al, TasP Workshop, April 2012

20 Decreasing prevalence of HIV drug resistance among patients on HAART % BCCfE DTP Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year: N: Suppressed Wild Type Never Genotyped 1-Class 2-Class 3-Class C Brumme, J Montaner and PR Harrigan. TasP Workshop, April 2012

21 Cascade of Care- HIV-RNA levels 100% 90% 80% 70% >=50000 >=10000 and <50000 >=3500 and <10000 Unsuppressed<3500 Suppressed 60% 50% 40% 30% 20% 10% 0% * Nosyk et al, in preparation, 2012

22 Increasing HAART Coverage within Evolving Guidelines in BC - Impact on New Diagnoses Updated from Montaner et al, Lancet, 2010, presented at TasP-Workshop, Vancouver 2012

23 Hepatitis C, Infectious Syphilis, BC BC x Canada x Canada Genital Chlamydia, Gonorrhea, BC x Canada x Canada BC

24 HIV+ tests by region by year (rate per 100,000 pop) British Columbia (-0.90, <0.0001) Alberta (0.12, 0.68) Ontario (0.04, 0.90) Quebec (-0.45, 0.11) Atlantic (-0.43, 0.13) Prairies (0.88, <0.0001) Hogg et al, CAHR, 2012

25 HIV Testing

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27 Routine HIV testing - Acute Care Site # Admissions # Offered # Tested Acceptance Rate SPH % MSJ % VGH % Total % % Offered % Tested # Positives Preliminary Results, Courtesy of Scott Harrison et al Positivity Rate Per % 39% 10 ~9/ % 46% 0 0/ % 26% 3 ~3/ % 34% 13 ~5/1000

28 New$Tes'ng$Guidelines$ 1. Normalize HIV Testing 2. Ongoing High Risk: Every 3 months 3. Ongoing Low Risk: Every 12 months 4. High Risk Event: Every 3 month until seroconversion window has passed

29 HIV Treatment

30 IAS-USA Guidelines: When to Start CD4+ Cell Count < 350 cells/mm³ cells/mm³ > 500 cells/mm³ Recommendation Start ART (AI) Start ART (AII) Start ART (BIII) Clinical Conditions Favoring Initiation of Therapy Regardless of CD4+ Cell Count History of AIDS-defining illness (AI) Pregnancy (AI) HIV-associated nephropathy (AII) HBV co-infection (AII) Patients at risk of transmitting HIV to sexual partners (AI, heterosexuals; AIII, others) HCV co-infection* (BII) Patients > 50 years of age (BIII) Offer ART to all HIV infected patients unless patient is elite controller or has stable CD4+ count and low HIV-1 RNA in absence of ART. Thompson MA, et al. JAMA. 2010;304;

31 DHHS, 2012: When to Start ART recommended for all HIV-infected patients strength of recommendation varies according to CD4+ cell count CD4+ Cell Count < 350 cells/mm³ cells/mm³ > 500 cells/mm³ Recommendation Start ART (AI) Start ART (AII) Start ART (BIII) Clinical Conditions Favoring Initiation of Therapy Regardless of CD4+ Cell Count History of AIDS-defining illness (AI) Pregnancy (AI) HIV-associated nephropathy (AII) HBV co-infection (AII) Patients at risk of transmitting HIV to sexual partners (AI, heterosexuals; AIII, others) HCV co-infection* (BII) Patients > 50 years of age (BIII) *Including those with high CD4 count and/or with cirrhosis. If CD4> 500/mm³ may elect to defer ART until after HCV therapy Rating of Recommendations: A = Strong; B = Moderate; C = Optional Rating of Evidence: I = data from RCTs; II = data from well-designed nonrandomized trials or cohort studies with long-term clinical outcomes; III = expert opinion DHHS Guidelines for Antiretroviral Therapy in Adults and Adolescents. March 27, 2012.

32 WHO Guidance on couples HIV testing and counselling Strong recommendation, high quality evidence. Released April 18 th 2012 at

33 Spectrum)of)Engagement)in)care)1)USA! 19% are estimated to be undetectable as a result of HAART use* * More recently CDC-USA revised the estimate to 28% Gardner)et)al.)CID,)2011)

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35 Let s talk about $$$

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38 HAART: Broad Societal Benefits of ART For every 1000 patient-years of treatment: 228 patient deaths averted 449 children not orphaned 61 sexual transmissions of HIV averted 26 vertical (mother-to-child) infections averted 9 TB cases averted among HIV patients 2.2 life-years gained Modified from Eric Goosby. TasP Workshop, April 2012

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40 Treatment 2.0: A new preventiontreatment paradigm in the global response to HIV/AIDS - UNGASS New York - 9 June 2010

41 TasP $An AIDS-Free Generation An AIDS-free generation would be one of the greatest gifts the United States could give to our collective future.

42 Few could have imagined that we d be talking about the real possibility of an AIDS-free generation. But that s what we re talking about make no mistake, we are going to win this fight. President Obama, December 1, 2011 PS: By the end of 2013, PEPFAR will directly support more than 6 M people on HAART 2M more than previously targeted.

43 "To cut new infections in half, we'll have to heed Julio Montaner's years of pleas to implement Treatment as Prevention and implement combination prevention programs. We can save a lot of lives if all this is done..." President Clinton, Washington AIDS Conference, 2012