Test and Treat:
Michael Saag, MD, FIDSAUniversity of Alabama, BirminghamDirector, Center for AIDS Research
or Halloween?
Is it All Saints Day ?
Updated from Chen, et al, 8th CROI, 2001
8 Year Survival in HAART Era
CD4 Count at HAART Initiation
Median CD4
% CD4 < 200
1996 115 62.8%1997 180 53.8%1998 221 47.8%1999 212 49.3%2000 197 50.1%2001 277 39.5%2002 210 48.8%2003 220 47.2%2004 207 49.1%
Median CD4
% CD4 < 200
2005 278 39.6%2006 300 35.4%2007 296 35.2%2008 310 29.4%
Key Point:
Many (? Most) HIV infected patients in the US don’t know they are infected
• Universal, opt-out testing is needed
Or is it….?
John Phillips: Libertarian “You gotta go where you wanna goDo what you wanna doWith whoever youWanna, wanna do it with….”
Slide 6
When To Start Treatment? –Summary of Current Guidelines
Guidelines symptomsorCD4 <200
CD4 200-350
CD4 >350
IAS-USA:JAMA 2008<www.iasusa.org>
treat treat Therapy should be considered and decision individualized
DHHS:<www.aidsinfo.nih.gov>
treat treat treat*
* Split opinion > 500
symptoms
Slide 7
When To Start Treatment? –Summary of Current Guidelines
Guidelines symptomsorCD4 <200
CD4 200-350
CD4 >350
IAS-USA:JAMA 2008<www.iasusa.org>
TREAT TREAT Therapy should be considered and decision individualized
DHHS:<www.aidsinfo.nih.gov>
TREAT TREAT TREAT*
* Split opinion > 500
symptoms
Slide 8
Cohort Study Results (NA-ACCORD / ART-CC)
Consequences of unchecked viral replication (Inflammation / Harm)
Improved tolerability / convenience of newer ARV regimens
Treatment reduces transmission of HIV Cost Savings
Reasons for Earlier Initiation of Therapy
Slide 9
Relative Time on Treatment…
30 35 40 45 50 55 60 65 70AGE (years)
CD4 650/ul
CD4 500/ul
40 years on Rx
35 years on Rx
5 years
Slide 10
Relative Time on Treatment…
30 35 40 45 50 55 60 65 70AGE (years)
CD4 650/ul
CD4 500/ul
40 years on Rx
35 years on Rx
5 years
HARM?
Slide 11Most New Infections Transmitted by
Persons who Do Not Know Their Status
~25% Unaware
of Infection
~75% Aware
of Infection
account for…
~54% New
Infections
~46% of New
Infections
Source: G. Marks et al. AIDS 2006
Slide 12
Prevention of Transmission
♦ TEST and TREAT – Testing and Linkage to Care (TLC+)
National AIDS Strategy…
ARV Receipt
Retention in Care
OutcomesHIV Dx Linkage
to CareARV
Adherence
Adapted from: Giordano et al. Curr HIV/AIDS Rep 2005;2:177-183, Samet et al. AIDS 2001;15:77-85, Eldred & Malitz. AIDS Pt Care STDs 2007;21:S1-2; Tobias et al. AIDS Pt Care STDs 2007;21:S3-8
Blueprint for HIV Treatment Success
ARV Receipt
Retention in Care
OutcomesHIV Dx Linkage
to CareARV
Adherence
Expanding the spectrum of adherence
25% of HIV-infected individuals in the U.S.
are undiagnosed
20-40% of newly diagnosed pts. fail to
establish care w/in 6 mos.
One-third of pts. w/ known HIV infection are not
engaged in care
Glynn & Rhodes. National HIV Prevention Conference 2005, Abstract 595, Gardner et al. AIDS 2005;19:423-431, Mugavero et al. Clin Infect Dis 2007;45:127-130, Fleming et al. 9th CROI 2002, abstract 11
Mean Annual Total Patient Costs by CD4 Count (cells/ul)
Mean Annual Total Patient Costs by Component
Key Points
• Mortality is much higher when patients are diagnosed late in the course of infection (CD4 < 200 /ul)
• The majority (> 50%) of newly diagnosed patients are diagnosed late (except preg Women)
• Many (? Most) HIV infected patients in the US don’t know they are infected
• Universal, opt-out testing is needed
With more universal testing, a 25 -50% increase in patient volume will occur
Who will take care of these patients?
Provision of medications
• “Every American who needs HIV treatment and care should have access to it”
• “People who are HIV-positive need essential medications”
• “Without the drugs, providing care is difficult to impossible”
PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7
Provision of HIV CARE• “Every American who needs HIV treatment
and care should have access to it”• “People who are HIV-positive need
essential medications”• “Without the drugs, providing care is
difficult to impossible”• “Without qualified HIV care providers and
clinics, HIV drugs mean nothing”
PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7
EDITORIAL COMMENTARY
Which Policy to ADAP-T:Waiting Lists or Waiting Lines?
Michael S. SaagUniversity of Alabama at Birmingham Center forAIDS Research
Clinical Infectious Diseases 2006;43:1365-1367© 2006 by the Infectious Diseases Society of America. All rights reserved.
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