Treatment as prevention it is complex let us work on it
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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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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

July 23rd, 2012 Session Room 2


Is treatment as prevention utopian

Is Treatment as Prevention Utopian?


Treatment as prevention it is complex let us work on it

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)


Still a long way to go to reach 15 million on art let alone treating everyone

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


Effective prevention interventions have not been brought to scale

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


Major inequities persist in access to treatment and prevention

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.


Who is prescribed art and who achieves viral suppression in the usa mmp

Who is Prescribed ART and Who Achieves Viral Suppression in the USA (MMP)?

* P value <0.05 Skarbinski, CROI, 2012


Clinical care system considerations addressing the hiv continuum of care

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


Early retention in care mugavero et al

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


Treatment as prevention it is complex let us work on it

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


Clinical care system considerations linkage retention and effectiveness usa

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


Looking ahead challenging times for hiv prevention

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


Treatment as prevention it is complex let us work on it

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


Treatment as prevention it is complex let us work on it

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


Treatment as prevention it is complex let us work on it

A combination of interventions has more impact than the interventions delivered alone

Source: Tim Hallett, personal communication


Combination antiretroviral prevention

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

.


Thank you

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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