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Treatment as Prevention: It is complex: Let us work on it

Treatment as Prevention: It is complex: Let us work on it. Kenneth H. Mayer Fenway Health Beth Israel Deaconess Hospital Harvard Medical School Boston, Mass

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Treatment as Prevention: It is complex: Let us work on it

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  1. Treatment as Prevention: It is complex: Let us work on it Kenneth H. Mayer Fenway Health Beth Israel Deaconess Hospital Harvard Medical School Boston, Mass July 23rd, 2012 Session Room 2

  2. Is Treatment as Prevention Utopian?

  3. Most PLHIV are unaware that they are infected Successful TasP requires massive ↑Testing Percentage of women and men who received an HIV test and test results in last 12 months, 2003–2010 (WHO/UNAIDS)

  4. Still a long way to go to reach 15 million on ART, let alone treating everyone 97% 53% Estimated gap: CD4 cell count ≤ 350/mm3 but not on ART 3% 47% Patients receiving ART WHO, 2011

  5. Effective prevention interventions have not been brought to scale Goal: ~ 20 million by 2016 Total MCs through 2011: ~1.35 million, 6.5% of target # Male circumcisions performed annually in 14 priority countries in eastern and southern Africa Source: WHO

  6. Major inequities persist in access to treatment and prevention Source: Global HIV/AIDS Response. Epidemic update and health sector progress towards Universal Access. Progress Report 2011. WHO/UNAIDS/UNICEF. Table 6.9, p. 137.

  7. Who is Prescribed ART and Who Achieves Viral Suppression in the USA (MMP)? * P value <0.05 Skarbinski, CROI, 2012

  8. Clinical Care System ConsiderationsAddressing the HIV Continuum of Care 80% 77% 51% 89% 77% 850,000 with HIV do not have virus under control (72%) MMWR (60), 2011

  9. Early retention in care (Mugavero et al) The first year in outpatient HIV medical care is a dynamic, formative & vulnerable time Poor early retention in care associated with: Delayed / failed antiretroviral therapy (ART) receipt Delayed time to VL suppression and greater cumulative HIV burden Increased sexual risk transmission behaviors Increased risk of clinical events & mortality Worse ART adherence, CD4 & VL response and increased long-term mortality following ART start Ulett et al. AIDS Pt Care STDS 2009;23, Giordano et al. JAIDS 2003;32, Metsch et al. Clin Infect Dis 2008;47, Mugavero et al. Clin Infect Dis 2009;48, Tripathi et al. AIDS Res Hum Retrovirus 2011;e-pub, Giordano et al. Clin Infect Dis 2007;44

  10. Linkage to Care: CDC ARTAS • Outcome: 1o HIV provider visit attended w/in: • Intervention is efficacious, but additional steps needed to promote linkage to care… Gardner et al. AIDS 2005;19

  11. Clinical Care System ConsiderationsLinkage, retention, and effectiveness (USA) • Linkage to care and preventive services • Only 69% of persons with HIV attend clinic within 12 months of diagnosis • Case management improves linkage by 32% at cost of $1,200 per person • Interventions focused on adherence increase likelihood of undetectable viral load by 15% • Effectiveness depends on coverage during entire cascade from testing to care • Transmission reductions can vary from 15% to 44% WalenskyClD2010, Marks AIDS 2010; CrepazAIDS 2006 11

  12. Looking Ahead:Challenging Times for HIV Prevention • Picture in the United States especially grim: • Federal deficit ~$1.3 trillion for FY 2011 • 5-year freeze on federal discretionary spending • Reductions in HIV prevention by health departments • ~45,000 state and local public health jobs lost • Staff furloughs, hiring freezes, pay cuts • Many community organizations closed or struggling • Similar picture being observed in other Western Industrialized settings, driven by economic downturn Kaiser Family Foundation; NASTAD; Center on Budget and Policy Priorities *Total includes HIV and viral hepatitis prevention programs, but majority of funds cut were from HIV

  13. Social Cognitive Model: TasP Needs to Consider Concomitant Issues Depression, anxiety, mental health problems Pleasure reduction Safer Sex Adherence Self efficacy Disease prevention Social Models Wulfert, Safren, et al., 1999; Journal of Applied Social Psychology

  14. HPTN 052: Lots of “Uncoupled” Transmissions Total HIV-1 Transmission Events: 39 Linked Transmissions: 28 Unlinked or TBD Transmissions: 11 • Up to 30% of new infections in couples occur outside the primary relationship (Campbell et al PLoS One 2011; Hughes et al. J Infect Dis 2011) Immediate Arm: 1 Delayed Arm: 27 p < 0.001

  15. A combination of interventions has more impact than the interventions delivered alone Source: Tim Hallett, personal communication

  16. Combination Antiretroviral Prevention Interventions to Increase Testing Enroll in Care Test HIV Negative HIV Positive ART Initiation Linkage To Care Treat Risk Assessment PrEP, Adherence Counseling Positive Prevention Adherence to ART Address concomitant concerns, e.g. depression, substance use, relationship dynamics Maintain Viral Suppression Decrease in HIV Transmission .

  17. Thank You Kevin Fenton Gottfried Hirnschall Tim Hallett Steven Safren JacekSkarbinski Michael Mugavero Wafaa El-Sadr NIAID, NIMH, NIDA, NICHD, CDC, HRSA, Mass DPH, Gilead www.thefenwayinstitute.org

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