Treatment as prevention tasp
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Treatment as Prevention ( TasP ). Dr Michael Brady Medical Director, Terrence Higgins Trust Consultant, HIV & Sexual Health.

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Treatment as Prevention ( TasP )

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Treatment as prevention tasp

Treatment as Prevention (TasP)

Dr Michael Brady

Medical Director, Terrence Higgins Trust

Consultant, HIV & Sexual Health


Treatment as prevention tasp

Reducing onward transmission: Viral suppression among key population groups living with HIV in the United Kingdom. 19th Annual Conference of the British HIV Association (BHIVA) April 2013, Valerie Delpech, Alison Brown, Stephano Conti, VenkataPolavarapu, Zing Yin


Treatment as prevention tasp

96% (73; 99)

Treatment for prevention

73% (49; 85)

Tenofovir/Truvada for discordant couples

Truvada for heterosexuals

63% (22; 83)

Medical male circumcision

54% (38; 66)

44% (15; 63)

Truvada for MSMs

Tenofovir vaginal (coital)

Prime boost Vaccine

39% (6; 60)

0% (-69; 41)

Truvada for women

31% (1; 51)

15% (-20; 40)

Tenofovir gel (daily)

for women

0% 10 20 30 40 50 60 70 80 90 100%

Study

Effect size (95% CI)

0% (-50; 30)

Truvada for women

Efficacy


Treatment as prevention tasp

HPTN 052 Study Design

Stable, healthy, serodiscordant couples, sexually active

CD4 count: 350 to 550 cells/mm3

Randomization

Immediate ART

CD4 350-550

Delayed ART

CD4 <250

Primary Transmission Endpoint

Virologically-linked transmission events

Primary Clinical Endpoint

WHO stage 4 clinical events, pulmonary tuberculosis, severe bacterial infection and/or death


Treatment as prevention tasp

HPTN 052: HIV-1 Transmission

Total HIV-1 Transmission Events: 39

96% reduction in HIV

Transmission

Linked Transmissions: 28

Unlinked or TBD Transmissions: 11

  • 18/28 (64%) transmissions from infected participants with CD4 >350 cells/mm3

  • 23/28 (82%) transmissions in sub-Saharan Africa

  • 18/28 (64%) transmissions from female to male partners

Immediate Arm: 1

Delayed Arm: 27

p < 0.001


Hiv treatment guidelines

HIV Treatment Guidelines


Treatment as prevention tasp

Reducing onward transmission: Viral suppression among key population groups living with HIV in the United Kingdom. 19th Annual Conference of the British HIV Association (BHIVA) April 2013, Valerie Delpech, Alison Brown, Stephano Conti, VenkataPolavarapu, Zing Yin


Distribution of viral load among gay men living with hiv in the uk in 2010

Distribution of viral load among gay men living with HIV in the UK in 2010

HIV treatment as prevention among men who have sex with men in the UK: is transmission controlled by universal access to HIV treatment and care?

AE Brown*,ON Gill, VC Delpech, Article first published online: 28 July 2013, HIV Medicine, Volume 14, Issue 9, pages 563–570, October 2013


What is the potential impact of starting treatment early

What is the potential impact of starting treatment early?

  • ART started at CD4 <500 could have reduced the proportion of PLWHIV with detectable viraemia from 42% to 38%

  • Halving the undiagnosed population could have led to to a decrease to 28%

    “Unlikely early treatment will reduce HIV transmission unless undiagnosed population is substantially reduced”

Brown et al AIDS 2014 Jan 14;28(2):281-3


What is the potential impact of starting treatment early1

What is the potential impact of starting treatment early?

  • Extending ART to all diagnosed HIV infected MSM with CD4 <500 in 2010 would reduce proportion of infectious men from 35% – 29%.

  • Halving the proportion who are undiagnosed would further reduce this to 21%

    “The effectiveness of treatment as prevention will be limited unless the undiagnosed population is reduced through frequent HIV testing and consistent condom use”

Brown et al AIDS 2014 Jan 14;28(2):281-3


Can we afford it

Can we afford it?

  • Estimated annual population treatment and care costs:

    • £104 million in 1997

    • £483 million in 2006

    • £721 million in 2013

Mandalia et al PLoS One 2010; 5:e15677


Summary tasp

Summary: TasP

  • The best evidence for effectiveness of an intervention to reduce transmission

  • Effectiveness depends on knowing HIV status and therefore interlinked with testing strategies

  • Cost may prohibitive


Treatment as prevention tasp

With limited resources do we focus on:

ART for HIV positive people?

ART for HIV negative people?

Reduced transmission

Reduced morbidity

Reduced mortality

Better quality of life

Low pill burden

Low toxicity

Reduced transmission

?cost

?adherence

?sexual behaviour

?other STIs


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