Thresia Sebastian MD, MPH University of Colorado, Denver Global Health Disasters Course October 2016 1
Objectives of today s lecture Describe global goals in the fight against HIV Review the epidemiology of global HIV Update on a cure for HIV Describe the strategies of primary prevention and positive prevention Describe the importance of treatment as prevention 2
Introduction Human Immunodeficiency Virus (HIV) has infected >78 million people, claimed >39 million lives, touched nearly every nation. ~ 90% of all HIV+ people live in developing countries. The incidence of new HIV infections has leveled off. Societal factors drive the spread of the epidemic, including people on the move, complex emergencies, cultural factors, poverty, stigma, and denial. 3
The global approach to stop the progress of HIV 4
What has happened in the last 15 years? # dying from HIV-related causes was reduced by 25% # newly infected was cut by >one third and # children newly infected declined by almost 60% Globally, the annual # acquiring HIV infection has been reduced by 35% since 2000 30 million people have avoided acquiring HIV infection 5
90-90-90 Current UNAIDS goals: To meet targets, 30 million need to be on ART by 2020 and 37 million by 2030 90% of all people living with HIV (PLHIV) knowing their HIV status 90% of all people diagnosed with HIV receive anti-retroviral therapy (ART) 90% of all people receiving ART will have viral suppression UNAIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. October 2014. 6
Key global gaps Only 54% of PLHIV know their status. 27% of pregnant women with HIV in 2014 didn't access antiretroviral drugs (ARVs) for prevention of mother to child transmission (PMTCT) 2014 UNAIDS- The Gap Report 7
Critical changes in areas most affected In the 21 priority countries, only 15% reduction in number of recent HIV infections in women of reproductive age b/w 2009 and 2014. Greatest gains in eastern and southern Africa. Coverage increased from 24% in 2010 to 54% in 2015, reaching a total of 10.3 million PLHIV AIDS-related deaths in the region decreased by 36% since 2010. UNAIDS. 2014 Progress report on the Global Plan toward the elimination of new infections among children by 2015 and keeping their mothers alive. 8
Key populations > 90% of new HIV infections in central Asia, Europe, North America, the Middle East and North Africa in 2014 were among key populations and their sexual partners. In the Asia and Pacific region, Latin America and the Caribbean, key populations and their sexual partners accounted for nearly two thirds of new infections. In sub- Saharan Africa, key populations accounted for >20% of new infections, and HIV prevalence among these populations is often extremely high. UNAIDS. Global AIDS Update 2016. 9
Global statistics PLHIV (all ages) New HIV infections (all ages) PLHIV on ART (all ages) AIDS-related deaths (all ages) 2010 33.3 million 2.2 million 7,501,100 1.5 million 2015 36.7 million (7%)* 2.1 million (9%)* 17,025,900 (5%)* 1.1 million (14%)* * children UNAIDS. Global AIDS Update 2016. 10
PLHIV by region 11
Number of PLHIV on ART globally UNAIDS. Global AIDS Update 2016. 12
The Impact of ART UNAIDS. Global AIDS Update 2016. 13
ART and life expectancy over time 2014 UNAIDS- The Gap Report 14
Global ART coverage 32% in children WHO HIV/AIDS Data and Statistics 2015 15
Annual maternal ART coverage in sub- Saharan Africa VT rate in LIC and MIC has been cut from 37% in 2000 to 15% in 2014. UNAIDS, UNICEF and WHO, 2005-2013 Global AIDS Response Progress Reporting and UNAIDS, 2005-2013 HIV and AIDS Estimates. WHO. Global Health sector response to HIV, 2000-2015. Focus on Innovations in Africa. 2015. 16
Why are people being left behind? 1. Human rights violations, stigma and discrimination 2. Access to treatment and services 3. Gender-based inequalities 4. Criminalization and exclusion 17
How to change the face of the epidemic 1. Meaningful participation of PLHIV 2. Improve services, including communitybased services 3. Scale up antiretroviral therapy and integrated health services 4. Increase treatment and rights awareness 18
Fast Track Focused efforts on where greatest impact can be made (especially on the 30 countries that account for most of the world s people newly infected with HIV) Stop what does not work and scale up proven programs Accelerate scale-up over next 5 years Achieve saturation with full range of high-impact HIV services for prioritized locations/ populations within the context of equality and non-discrimination Highlight human rights approach 19
The impact of community- based services 2014 UNAIDS- The Gap Report 20
Scaling up treatment and integrated services Gisslen M et al, Sweden, the first country to achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) 90-90-90 continuum of HIV care targets. HIV Medicine, August 18, 2016. 21
But what about a cure? Photo credit: www.just4info.org 22
Vaccine The development/discovery of a safe and effective HIV vaccine is the most effective path to eradicate HIV. After ~30 years of HIV vaccine research, only five efficacy trials have been conducted and only one (RV144) provided evidence of protective immunity(modest). There is momentum in the race towards discovery of the HIV vaccine but a cure is still years away. 23
Functional Cure Berlin patient The Boston cures Mississippi Baby Visconti cohort Canadian Foundation for AIDS Research: www.canfar.com 24
And in the meantime? Until a cure is discovered, prevention and treatment remain the most realistic strategies for dealing with the HIV epidemic. Success in prevention requires: Consistent and persistent intervention over time A clear understanding of the realities of target populations Empowered participation by those affected by the interventions 25
Primary Prevention Key strategies include: Ensuring individuals learn their HIV status Disclosure of HIV status to partners HIV testing partners Prevention of pregnancies and MTCT Voluntary medical male circumcision (VMMC) Pre-exposure prophylaxis (PrEP) 26
VMMC When safely provided by welltrained health professionals, reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Key intervention in generalized epidemic settings with high HIV prevalence/low male circumcision rates. Since 2011, >11 million men circumcised and projected to avert 335,000 HIV infections by 2025 and nearly half a million infections by 2030. WHO Progress Brief, VMMC for HIV prevention in 14 priority countries in east and southern Africa. June 2016 27
PrEP 12 trials of the effectiveness of oral PrEP have been conducted among serodiscordant couples, heterosexual men, women, MSM, people who inject drugs and transgender women. These trials took place in Africa, Asia, Europe, South America and the United States. WHO Policy brief on PrEP. November 2015 Photo credit: www.avert.org 28
Positive Prevention (1) Historically, prevention has been focused on reducing HIV infection risk among HIV negative/ unknown serostatus. More efficient to change behavior among the smaller HIV+ population than the larger HIV- one: This is a strategy known as positive prevention, or prevention for, by or with positives and, most recently, positive health, dignity and prevention. 29
Positive Prevention (2) Four main goals: Keeping HIV + individuals physically healthy Keeping such persons mentally healthy Preventing further transmission of HIV Involving PLHIV in prevention activities, leadership and advocacy Kennedy C, Medley A, Sweat M, O Reilly K. Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bulletin of the World Health Organization 2010;88:615-623 Photo credit: HIVST.org (http://www.hivst.org/alternative-venues-experience/) 30
Treatment as Prevention (TasP) In 2012, the WHO introduced the concept of treatment as prevention an HIV prevention method that uses ART in HIV+ persons to decrease the chance of HIV transmission. Based on the idea that treatment of HIV index cases with ART will reduce their viral loads and cause them to be less infectious to their sexual partners. 31
Treatment as Prevention (2) TasP has led many countries to test and treat all HIV infected individuals ensuring universal HIV testing and ART initiation on all HIV+ individuals regardless of CD4 count/viral load. However, the effectiveness of TasP relies heavily on the willingness and ability of people on ART to remain in care and adhering to their regimen correctly. 32
The START study- 2015 Enrolled >4,600 HIV+ people from 35 countries with a CD4 >500. Half of participants started ART straight away and half waited until CD4 reached 350. Early ART more than halved the risk of a serious illness. Even though the actual risk was low most people did well in both groups the difference between the two groups was highly significant. More clear evidence for benefits of test and treat The INSIGHT START Study Group, Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection, N Engl J Med 2015; 373:795-807August 27, 2015 33
The Challenge Retention Adherence Donor Fatigue Drug toxicities Stigma Every five years we have more than doubled the number of people on life-saving treatment. We need to do it just one more time to break the AIDS epidemic and keep it from rebounding. - Michel Sidibé, Executive Director, UNAIDS 34
Giving a voice to the voiceless 2014 UNAIDS- The Gap Report 35
Take-home Points The incidence of new HIV infections has leveled off but many challenges remain to ensure the rapid end of the epidemic UNAIDS goal of 90-90-90 is an ambitious global target to ensure the end of the AIDS epidemic by 2020 We are still years away from the discovery of an AIDS cure; in the meantime, prevention and treatment strategies such as TasP remain the most realistic strategies for dealing with the HIV epidemic 36
ENDING THE AIDS EPIDEMIC IS POSSIBLE Summon the courage to change the world UNAIDS Speeches December 7, 2013 37