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
Since the beginning of the epidemic 70 million infections 35 million deaths
Phases of HIV Epidemic 1980-2020 Devastation Discovery End of AIDS 1980 1985 1990 1995 2000 2005 2010 2015 2020 1981 AIDS 1983 HIV 1983 WHO surveillance 1983 Denver Principles 1980 100,000 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 25-44 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 1995 20M PLHIV No Tx 2001 Special UN Session global emergency 2002 Leading cause of death 2002 Global Fund established 2003 PEPFAR 2003 WHO 3x5 2000 34.3M PLHIV 1M (3%) Tx Africa 50,000 (2%) 2005 1 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 2005 40.3M 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 90-2010 90-90 33.3M 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 2016 18.2 M (49%)people on treatment 2016 Cumulative 39 million AIDS deaths 2015 36M PLHIV 16M (44%) Tx 2020 90-90-90 reached 2020 95-95-95 targets affirmed 2020 37M PLHIV 27 (81%) Tx Policy Hit early, hit hard. Almost no access to treatment in low and middle income countries 2003 WHO CD4 <200 2009 WHO CD4 <350 2012 US Treat All 2013 WHOCD4 <500 2015 WHO Irrespective CD4 Granich Lancet 2017
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
HIV/AIDS before ART
Antiretroviral Therapy works: Treatment for treatment Prevents disease progression Restores immune health Early treatment: Reduced death Reduced cancer Reduced tuberculosis
Decline in HIV incidence and mortality over time 3 500 000 3 000 000 People dying from AIDS-related causes globally People newly infected with HIV/AIDS globally 2 500 000 2 000 000 1 500 000 1 000 000 500 000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: UNAIDS/WHO estimates.
Annual number of new HIV infections 2010-2016 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%)
2016 36.7M living with HIV 1M deaths 1.8M new infections 5000 new infections per day
Antiretroviral Therapy works: Prevention Post-exposure prophylaxis (PEP) Prevention of vertical transmission (PMTCT)
TREATMENT IS PREVENTION
The OPPOSITES ATTRACT Study (2017)
U=U Undetectable Equals Untransmittable
ENDING AIDS TARGET BY 2030 UNAIDS new Global Direction
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.
Number of people living with HIV on antiretroviral therapy, global, 2010 2015 2015 target within the 2011 United Nations Political Declaration on HIV and AIDS Sources: Global AIDS Response Progress Reporting (GARPR) 2016; UNAIDS 2016 estimates.
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)
90-90-90 and The HIV Care Continuum Diagnosed PLHIV Diagnosed PLHIV on ART PLHIV on ART Virally Suppressed 90-90-90 Targets 90% 90% 90% Diagnosed PLHIV PLHIV on ART PLHIV Virally Suppressed HIV Care Continuum 90% 81% 73%
Program Interventions that address the HIV care CONTINUUM 90-90-90 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
J Justman, CROI2017 :not too ambitious, but a really good start
Proportion of people living with HIV diagnosed Top 21 countries reporting more than 84% of people living with diagnosed HIV (2010-2016) 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
Proportion of people living with HIV on ART Top 21 countries reporting more than 64% of people living with HIV on ART (2010-2016) 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
Top 20 countries reporting more than 53% of people living with HIV with viral suppression (2010-2016) 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
CAMBODIA IS ON TRACK TO ACHIEVE THE 90-90-90 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 2025. MAM BUN HENG MINISTER OF HEALTH, CAMBODIA
HIV & AIDS Epidemic in Malaysia Comparison of New HIV Infections between Injecting Drug Users (IDU) & Sexual Transmission (2005-2016) Source: HIV/STI Sector, Division of Disease Control, Ministry of Health Malaysia
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 (2016 2018): 34 16 Projects, 52 Government Clinics - PWID, SW & MSM Program.
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
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
Case Management All KPs January 2017- December 2017 10658 KP reached 5461 (51%) underwent HIV test 467 (8.5%) KPs tested HIV+ 131 (28%) KPs on HAART
Case Management - PWID January 2017- December 2017 4713 PWID reached 2346 (50%) underwent HIV test 104 (4.4%) PWID tested HIV+ 27 (25%) PWID on HAART
Case Management SW/TG January 2017- December 2017 3488 SW/TG reached 1459 (42%) underwent HIV test 66 (4.5%) SW/TG tested HIV+ 22 (33%) SW/TG on HAART
Case Management - MSM January 2017- December 2017 2457 MSM reached 1656 (67%) underwent HIV test 297 (18%) MSM tested HIV+ 82 (28%) MSM on HAART
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.
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
Mean Score 90 80 70 60 50 40 30 20 10 0 The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia 80.3 73.2 P<0.0001 59.4 51.2 P<0.0001 Medical Students (N=486) Dental Students (N=658) 39.9 35.7 P<0.0001 33.3 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
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
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.
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
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
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