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HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International IAS-USA-Society Panel

Jeanne M. Marrazzo, MD, MPH; Carlos del Rio, MD; David R. Holtgrave, PhD; Myron S. Cohen, MD; Seth C. Kalichman, PhD; Kenneth H. Mayer, MD; Julio S. G. Montaner, MD; Darrell P. Wheeler, PhD, MPH; Robert M. Grant, MD, MPH; Beatriz Grinsztejn, MD, PhD; N. Kumarasamy, MD, PhD; Steven Shoptaw, PhD; Rochelle P. Walensky, MD, MPH; François Dabis, MD, PhD; Jeremy Sugarman, MD, MPH; Constance A. Benson, MD

Marrazzo et al, JAMA, 2014.


HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International Antiviral Society-USA Panel

Free web access to the paper at jama.com


Ias usa hiv prevention recommendations goal
IAS-USA HIV Prevention Recommendations: Recommendations of the International Antiviral Society-USA PanelGoal

  • Worldwide, ~2.3 million new HIV infections in 2012

    • In US, ~50,000 new HIV infections each year—largely unchanged since the 1990s

  • Integrated biomedical and behavioral HIV prevention tools and ART for treatment offer chance to curb the HIV epidemic

  • Clinicians play a crucial role in implementing combination HIV prevention interventions

  • These recommendations seek to consolidate best practices for clinicians across a range of HIV prevention issues

Marrazzo et al, JAMA, 2014.


Ias usa hiv prevention recommendations process
IAS-USA HIV Prevention Recommendations: Recommendations of the International Antiviral Society-USA PanelProcess

In 2013, international panel of HIV experts assembled by IAS-USA to develop evidence-based recommendations that integrate biomedical and behavioral interventions for HIV prevention in the clinical care setting

IAS-USA, a 501(c)(3) not for profit organization that sponsors CME for physicians and medical practitioners involved in the care of people with HIV, HCV, or other viral infections, sponsored and provided all funding for the recommendations

Volunteer panel members worked in teams to review and summarize scientific evidence and propose recommendations

Final recommendations approved by panel consensus; ratings assigned based on strength of recommendation and quality of evidence


Ias usa hiv prevention recommendations panel
IAS-USA HIV Prevention Recommendations: Recommendations of the International Antiviral Society-USA PanelPanel

Cochairs

Jeanne M. Marrazzo, MD, MPH

University of Washington

Carlos del Rio, MD

Emory University

David R. Holtgrave, PhD

The Johns Hopkins Bloomberg

School of Public Health

Members

Myron S. Cohen, MD

University of North Carolina

Seth C. Kalichman, PhD

University of Connecticut

Kenneth H. Mayer, MD

Harvard Medical School

Julio S. G. Montaner, MD

University of British Columbia

Darrell P. Wheeler, PhD, MPH

Loyola University Chicago

Robert M. Grant, MD, MPH

University of California San Francisco

Beatriz Grinsztejn, MD, PhD

EvandroChagas Clinical

Research Institute (IPEC)–FIOCRUZ

N. Kumarasamy, MD, PhD

YR Gaitonde Centre for AIDS Research

and Education

Steven Shoptaw, PhD

University of California Los Angeles

Rochelle P. Walensky, MD, MPH

Massachusetts General Hospital

François Dabis, MD, PhD

Université de Bordeaux

Jeremy Sugarman, MD, MPH

The Johns Hopkins University

Constance A. Benson, MD

University of California San Diego

Margaret A. Fischl, MD

University of Miami


Ias usa hiv prevention recommendations rating system
IAS-USA HIV Prevention Recommendations: Recommendations of the International Antiviral Society-USA PanelRating System

Adapted in part from Canadian Task Force on the Periodic Health Examination, Can Med Assoc J,1979


Ias usa hiv prevention recommendations sections
IAS-USA HIV Prevention Recommendations Recommendations of the International Antiviral Society-USA Panel: Sections

HIV Testing and Knowledge of Serostatus

Prevention Measures for HIV-Infected Individuals

Prevention Measures for HIV-Uninfected Individuals

Prevention Issues Relevant to All Persons With or At Risk for HIV Infection

Marrazzo et al, JAMA, 2014.


Hiv testing and knowledge of serostatus
HIV Testing and Knowledge of Recommendations of the International Antiviral Society-USA PanelSerostatus

Marrazzo et al, JAMA, 2014.


Hiv testing and knowledge of serostatus1
HIV Recommendations of the International Antiviral Society-USA PanelTesting and Knowledge of Serostatus

Marrazzo et al, JAMA, 2014.


Hiv testing and knowledge of serostatus cont d
HIV Recommendations of the International Antiviral Society-USA PanelTesting and Knowledge of Serostatus(cont’d)

Marrazzo et al, JAMA, 2014.


Hiv testing and knowledge of serostatus cont d1
HIV Recommendations of the International Antiviral Society-USA PanelTesting and Knowledge of Serostatus(cont’d)

Marrazzo et al, JAMA, 2014.


Prevention measures for hiv infected individuals
Prevention Measures for Recommendations of the International Antiviral Society-USA PanelHIV-Infected Individuals

Marrazzo et al, JAMA, 2014.


Antiretroviral therapy
Antiretroviral Recommendations of the International Antiviral Society-USA PanelTherapy

Marrazzo et al, JAMA, 2014.


Counseling on risk reduction disclosure of hiv serostatus and partner notification
Counseling on Risk Reduction, Disclosure of HIV Recommendations of the International Antiviral Society-USA PanelSerostatus, and Partner Notification

Marrazzo et al, JAMA, 2014.


Needle exchange and other harm reduction interventions
Needle Exchange and Other Recommendations of the International Antiviral Society-USA PanelHarm Reduction Interventions

Marrazzo et al, JAMA, 2014.


Strategies for promoting movement through the continuum of hiv care
Strategies for Promoting Recommendations of the International Antiviral Society-USA PanelMovement Through the Continuum of HIV Care

Marrazzo et al, JAMA, 2014.


Risk assessment and risk reduction for hiv infection
Risk Assessment and Risk Reduction for HIV Recommendations of the International Antiviral Society-USA PanelInfection

Marrazzo et al, JAMA, 2014.


Prevention measures for hiv uninfected individuals
Prevention Measures for Recommendations of the International Antiviral Society-USA PanelHIV-Uninfected Individuals

Marrazzo et al, JAMA, 2014.


Efficacy of Biomedical Interventions to Prevent HIV Acquisition: Summary of the Evidence from Randomized Clinical Trials

Modified from Ambitious Treatment Targets: Writing the Final Chapterof the AIDS Epidemic, UNAIDS, 2014.


Preexposure prophylaxis prep
Preexposure Acquisition: Summary of the Evidence from Randomized Clinical Trials Prophylaxis (PrEP)

Marrazzo et al, JAMA, 2014.


Preexposure prophylaxis cont d
Preexposure Acquisition: Summary of the Evidence from Randomized Clinical TrialsProphylaxis (cont’d)

Marrazzo et al, JAMA, 2014.


Preexposure prophylaxis cont d1
Preexposure Acquisition: Summary of the Evidence from Randomized Clinical Trials Prophylaxis (cont’d)

Marrazzo et al, JAMA, 2014.


Postexposure prophylaxis pep
Postexposure Acquisition: Summary of the Evidence from Randomized Clinical Trials Prophylaxis (PEP)

Marrazzo et al, JAMA, 2014.


Voluntary medical male circumcision
Voluntary Medical Male Circumcision Acquisition: Summary of the Evidence from Randomized Clinical Trials

Marrazzo et al, JAMA, 2014.


Prevention measures for all individuals with or at risk for hiv infection
Prevention Measures for All Individuals With or at Risk Acquisition: Summary of the Evidence from Randomized Clinical Trialsfor HIV Infection

Marrazzo et al, JAMA, 2014.


Screening and treatment for stis
Screening and Treatment for Acquisition: Summary of the Evidence from Randomized Clinical TrialsSTIs

Marrazzo et al, JAMA, 2014.


Screening and treatment for stis cont d
Screening and Treatment for Acquisition: Summary of the Evidence from Randomized Clinical TrialsSTIs(cont’d)

Marrazzo et al, JAMA, 2014.


Reproductive health care hormonal contraception
Reproductive Health Acquisition: Summary of the Evidence from Randomized Clinical TrialsCare/Hormonal Contraception

Marrazzo et al, JAMA, 2014.


Summary
Summary Acquisition: Summary of the Evidence from Randomized Clinical Trials

  • After 30 years, an AIDS-free generation could be a reality

  • Clinicians’ efforts are needed to:

    • Offer all adults and adolescents HIV testing

      For all persons with, or at risk for, HIV:

    • Regularly assess substance use and sexual risk practices

    • Offer ART and adherence support at diagnosis of HIV; PrEP and adherence support to those at risk

    • Have a high index of suspicion for nonspecific presentation of symptomatic acute HIV infection

    • Emphasize and support linkage to care

    • Facilitate individualized risk-reduction counseling

    • Conduct regular STI screening

Marrazzo et al, JAMA, 2014.


Trends in annual age adjusted rate of death due to hiv infection united states 1987 2010
Trends in Annual Age-Adjusted* Rate of Death Acquisition: Summary of the Evidence from Randomized Clinical TrialsDue to HIV Infection, United States, 1987−2010

Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account

for ICD-10 rules instead of ICD-9 rules.

*Standard: age distribution of 2000 US population


Hiv continuum of care
HIV Continuum of Care Acquisition: Summary of the Evidence from Randomized Clinical Trials

General population: 9.2% engaging in risk behaviors

HIV-positive: 1,144,500

Diagnosed with HIV: 963,600

Diagnosed with HIV in 2011:

79.8% linked to care

Diagnosed with HIV as of 2010:

50.9% retained in care

Diagnosed with HIV as of 2010: 327,485 with

viral load <200

copies/ml

~50K new infections per year

28.6% virologically suppressed

Source: CDC, 2013 and Holtgrave et al, 2012


Hiv continuum of care1
HIV Continuum of Care Acquisition: Summary of the Evidence from Randomized Clinical Trials

Approx 1.1 million with HIV in US

Source: CDC, http://aids.gov/federal-resources/policies/care-continuum/.


The need for hiv prevention continued hiv risk in the us
The Need for HIV Prevention: Acquisition: Summary of the Evidence from Randomized Clinical TrialsContinued HIV Risk in the US

  • Estimated new HIV infections in the United States for the most affected subpopulations, 2008-2011

70

60

Male-to-male sexual contact

Heterosexual contact

IDU

Male-to-male sexual contact and IDUOther

50

40

Diagnoses (%)

30

20

10

0

2008

2009

2010

2011

Yr

CDC. HIV in the United States: 2013.


Rationale for routine hiv screening initial cd4 cell count na accord
Rationale for Routine HIV Screening: Acquisition: Summary of the Evidence from Randomized Clinical TrialsInitial CD4 Cell Count (NA-ACCORD)

Althoff KN, et al. Clin Infect Dis. 2010;50:1512-20.


Rationale for routine hiv screening initial cd4 and response to haart

Median CD4+ cell count after Starting HAART (by baseline CD4+ category)

Rationale for Routine HIV Screening:Initial CD4 and Response to HAART

  • Palella FJ, et al. 2010 CROI. Abstract 983.

> 500

350-499

200-349

50-199

< 50


Rationale for routine hiv screening initial cd4 and response to haart1

Median CD4+ cell count after Starting HAART (by baseline CD4+ category)

Rationale for Routine HIV Screening:Initial CD4 and Response to HAART

  • Palella FJ, et al. 2010 CROI. Abstract 983.

> 500

350-499

200-349

50-199

< 50


Earlier diagnosis h as benefits ignorance is not bliss

Marks et al. AIDS, 2006 CD4+ category)

Earlier Diagnosis Has Benefits: Ignorance is Not Bliss

New infections

Living with HIV: 1.1M

~21% unaware

54-70%

Transmission

30-46%

~79% aware

Marks et al. AIDS, 2006


IAS CD4+ category) USA

Antiretroviral Guidelines

1996 – 2014

Günthard et al, JAMA, 2014.


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