Treatment as Prevention: The Key to an AIDS-Free Generation
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Transcript of Treatment as Prevention: The Key to an AIDS-Free Generation
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IAS–USA
Julio S. G. Montaner, MDProfessor of Medicine
University of British Columbia
Treatment as Prevention:The Key to an AIDS-Free Generation
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Impact of HAART in BC-CfE
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1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
Death Rate per 1000
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1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
Life Expectancy at age 20
Modified from Hogg et al, Lancet. 2009
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Slide 3 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
New HIV and Syphilis in BC
BC-CDC, 2005
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 4 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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Slide 5 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HAART stops HIV replication
HIV load falls to undetectable levels in plasma
as well as in sexual fluids
Sharp reduction in HIV transmission
Slide 5 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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Slide 6 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Wood et al, BMJ, 2009
Whiskers represent 95% confidence intervals.
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HAART Reduces HIV incidence in IDUs
• From 1997, HIV incidence decreased by 74%
for each log decline in community HIV viral load
• In a separate model, HIV incidence decreased
by 5% for each 1% increase in HAART coverage
Modified from G Kirk et al, for the Alive Cohort, CROI 2011
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HR = 96.3% reduction in transmission
No difference whether index pt was M or F
Deferred
Immediate
%
HPTN 052: Immediate vs Delayed ART in Sero-discordant Couples
Cohen MS, et al. IAS 2011. Abst MOAX0102 Cohen MS, et al. N Engl J Med. 2011
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
January 2004
Summer of 1996
Year
Summer of 2000
Phase I Phase II Phase III
Montaner et al, Lancet, 2010
Increasing HAART Coverage within Evolving Guidelines in BC
N = 7492 by the end of 2011
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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Slide 10 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
BC: AIDS Cases Diagnosed (Rate per 100K)
> 80% Decrease in AIDS case report rate in BC since the pre cART era
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
BC: All Cause Mortality (#)
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Years
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y
> 90% Decrease in All Cause Mortality among HIV Infected Individuals in BC since 1996
Montaner et al, TasP Workshop, April 2012
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA. Updated from Montaner et al, Lancet, 2010, presented at TasP-Workshop, Vancouver 2012
Increasing HAART Coverage within Evolving Guidelines in BC - Impact on New Diagnoses
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Hepatitis C, 1999-2008 Infectious Syphilis, 1999-2008
Genital Chlamydia, 1999-2008 Gonorrhea, 1999-2008
• BC
x Canada
• BC
x Canada
• BC
x Canada• BC
x Canada
2004
2004 2004
2004
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 14 of 20
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Routine HIV testing - Acute Care
Preliminary Results, Courtesy of Scott Harrison et al
Site1
Number of
Admissions
Number Offered
Number Tested
Acceptance Rate2 % Offered % Tested
Number of Positives
Positivity Rate per 1000
SPH 3610 1626 1370 97% 45% 38% 11 ~ 8/1000
MSJ 1556 994 740 85% 64% 48% 3 ~ 4/1000
VGH 2087 1512 1196 96% 34% 27% 4 ~ 3/1000
Total 9653 4132 3306 94% 43% 34% 18 ~ 5/1000
Department of Medicine Chart Audit Data: October 2011 –December 2, 2012
1 Departments of Medicine only at each hospital site2 Acceptance rate excludes all “Not Accepted” (i.e. recent test, known HIV positive) except Pt Refusal
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Spectrum of Engagement in Care - USA
Gardner et al. CID, 2011
19% are estimated to be undetectable as a result of
HAART use*
* More recently CDC-USA revised the estimate to 28%
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
The Cascade of Care - 1996-2010
*
Diagnosed Linked Retained Need_ARV on ARV AdherentSuppressed
0%
10%
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Nosyk et al, CROI, 2013
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From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Granich et al
Lives Saved (x 1,000) U$A Billions