Treatment as Prevention · Julio Montaner MD, FRCPC, FCCP Director, BC-Centre for Excellence on...

British Columbia Centre for Excellence in HIV/AIDS

Julio Montaner MD, FRCPC, FCCPDirector, BC-Centre for Excellence on HIV/AIDS, Providence Health Care

Professor of Medicine and Chair, AIDS Research, University of British ColumbiaPresident, International AIDS Society

WHO, Geneva, Nov 2009

Treatment as Prevention:HAART Expansion - A Powerful Strategy to Reduce

AIDS Morbidity and Mortality and HIV Incidence

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Effect of HAART on HIV Transmission

HAART stops HIV replication

↓

HIV levels fall to undetectable in

blood as well as sexual fluids

↓

Sharp reduction in HIV transmission

Prevention Strategies

- Education- Change in behavoir- Harm reduction- New strategies/technology- Vaccines

Existing strategies have failed to contain the global HIV pandemic

PERINATAL HIV TRANSMISSION AND MATERNAL VIRAL LOAD: CIHR - CTN CANADIAN PERINATAL HIV SURVEILLANCE PROGRAM (CPHSP)

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Discordant Couples

S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS. 2009 Jul 17;23(11):1397-404



Discordant Couples

S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS. 2009 Jul 17;23(11):1397-404

Conclusion: Studies of heterosexual discordant couples observed no transmission in patients treated with ART and with viral load below 400 copies/ml, but data were compatible with

one transmission per 79 person-years.



Anema et al Eur Jour of Inf Dis, 2009





Anema et al Eur Jour of Inf Dis, 2009



~ 80%

~ 20%

To evaluate the relationship between “community plasma HIV RNA” and HIV incidence among injection drug users

Conducted within Vancouver’s DTES

Using two concomitant sister cohorts (VIDUS)

HIV+ IDUs

HIV- IDUs



decompressorare needed to see this picture.

Whiskers represent 95% confidence intervals.

Community plasma HIV RNA levels in a cohort of injection drug users in Vancouver’s DTES

Wood et al, BMJ, May 16, 2009

HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals.

HIV incidence in a cohort of injection drug users in Vancouver’s DTES


Community plasma HIV RNA levels and HIV incidence among two parallel cohorts of IDUs

HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals.


A Formidable Challenge

A Unique Opportunity

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Yea

Treat all Treat 30%

HIV prevalence

Montaner et al, Lancet 2006

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Treat all

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The Power of HAART: Demographic Model



R Granich, C Gilks, C Dye, K De Cock, B Williams. The Lancet Nov 26th 2008



New Data

Work in ProgressStrictly Confidential

Prospectively Evaluate the Impact of HAART Expansion on AIDS Morbidity and Mortality and HIV Incidence in BC

Intervention Primary EndpointHAART Expansion HIV Incidence within medical guidelines at years 3 to 5

Secondary Endpoints:

MORBIDITY AND MORTALITY, CD4 COUNTS, HIV-1-RNA LEVELS,

RESISTANCE, ADVERSE EVENTS, SAFETY, ADHERENCE,

HOSPITALIZATIONS, RESOURCE UTILIZATION

STOP HIV & AIDSSTOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS*

* Supported through a five year Avant Garde Award by the National Institute for Drug Abuse (NIDA) at the NIH



HIV Reportable

Modified from Montaner et al, Lancet, 2006

HIV Reportable



HIV Reportable

Modified from Montaner et al, Lancet, 2006

Decrease in HIV new cases attributed to initial roll out of

HAART between 1996 and 1999, consistent with that seen in

Taiwan (JID, 2005)

HIV ReportableHIV Reportable



HIV Reportable

Montaner et al, Work in Progress 2009

HIV ReportableHIV Reportable

Decrease in HIV new cases attributed to initial roll out of

HAART between 1996 and 1999, consistent with that seen in

Taiwan (JID, 2005)

January 2004



January 2004

Note that the expansion of HAART here described occurred prior to the new 2008 IAS-USA

Guidelines, which were adopted in BC at the end of 2008

Jan 2004

January 2004

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t. 28

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³ 50,000 10,000 - 49,999 3500 - 9999500 - 3499 < 500

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Highest pVL January 2004

“Average” pVL

HAART has a substantial added preventive value

The magnitude of this effect is not yet fully characterized, and may well

vary in different settings

Seek and Treat among those who have a medical indication for

HAART cannot wait for the above to be resolved

Many lives will be saved and much insight will be gained from closely

monitoring a more “aggressive”roll out of HAART

Seek and Treat outside the area where treatment is medically

indicated remains a research question

However, current guidelines, if liberally applied, may leave relatively few

outside the “treatment envelope”

Seek and Treat will only be effective as part of a comprehensive

Combination Prevention strategy that includes strong HR protection

Treatment as Prevention:HAART Expansion - A Powerful Strategy to Reduce AIDS Morbidity and

Mortality and HIV Incidence

All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time.

Bradford-Hill, A. 1965 The environment and disease: Association or Causation? Presidentaddress at January 14 meeting. Proceedings of the Royal Society of Medicine 163 (seriesB): 295-300.

A Statistician’s Opinion

AIDS Nov 27th 2008, The EconomistDeploying the drugs used to treat AIDS may be the way to limit its spread



Illustration by Peter Schrank

Thank you

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Highest pVL

January 2004

January 2004

Combination prevention

Community Interventions

Biomedical Interventions

Structural Interventions

HIV testing and linkage

to care

Individual and small

group behavioral

interventions

HIV prevention

Adapted from T Coates



Thank You

British Columbia British Columbia Centre for Excellence Centre for Excellence in HIV/AIDSin HIV/AIDS

British Columbia Centre for Excellence in HIV/AIDS

STOP HIV & AIDSSTOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS

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R Hogg, E Wood, T Kerr, M Tyndall, A Levy, PR Harrigan, V Lima, A Anema, Pedro Cahn, Jose Esparza, Craig Mc Clure

ART Guidelines Panel, IAS - USABC-MoH

SPH FoundationPharmaceutical Industry

MSHRF, CIHR, NIDA and NIHH&W, Ottawa

Research Staff and Study Participants

Treatment as Prevention · Julio Montaner MD, FRCPC, FCCP Director, BC-Centre for Excellence on...

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