From efficacy to effectiveness:
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From efficacy to effectiveness: HIV seroincidence by ART status among HIV discordant couples in Zambia. Kristin M. Wall , PhD [email protected] Department of Epidemiology Rwanda Zambia HIV Research Group Emory University, Atlanta, GA, USA. Conflict of Interest Disclosure.

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Kristin M. Wall , PhD [email protected] Department of Epidemiology

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Kristin m wall phd kmwall emory department of epidemiology

From efficacy to effectiveness: HIV seroincidence by ART status among HIV discordant couples in Zambia

Kristin M. Wall, PhD

[email protected]

Department of Epidemiology

Rwanda Zambia HIV Research Group

Emory University, Atlanta, GA, USA


Conflict of interest disclosure

Conflict of Interest Disclosure

The authors have no conflicts of interest due to financial or personal relationships that might be perceived to cause bias.


Acronyms for this talk

Acronyms for this talk

TasP:Antiretroviral treatment (ART)-as-prevention

  • For the purposes of this talk, ART has been provided for therapeutic reasons only

    CVCT: Couples’ voluntary HIV counseling and testing

  • Joint pre-test counseling

  • Rapid HIV testing

  • Joint post-test counseling


Kristin m wall phd kmwall emory department of epidemiology

  • CVCT: transmission in serodiscordant couples by 2/3

  • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

  • TasP: 96% efficacy in serodiscordant couples

  • (Cohen et al, NEJM, 2011)


Kristin m wall phd kmwall emory department of epidemiology

  • CVCT: transmission in serodiscordant couples by 2/3

  • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

  • TasP: 96% efficacy in serodiscordant couples

  • (Cohen et al, NEJM, 2011)

CVCT

WHO, 2012 (Recs 1-3)

TasP

WHO, 2012 (Recs 5)


Kristin m wall phd kmwall emory department of epidemiology

  • CVCT: transmission in serodiscordant couples by 2/3

  • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

  • TasP: 96% efficacy in serodiscordant couples

  • (Cohen et al, NEJM, 2011)

CVCT

WHO, 2012 (Recs 1-3)

TasP

WHO, 2012 (Recs 5)

CVCT: WHO Recs 1-3

TasP: WHO Rec 5

(WHO, 2012)

  • Real-world TasPeffectiveness in discordant couples?


Kristin m wall phd kmwall emory department of epidemiology

  • CVCT: transmission in serodiscordant couples by 2/3

  • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

  • TasP: 96% efficacy in serodiscordant couples

  • (Cohen et al, NEJM, 2011)

CVCT

WHO, 2012 (Recs 1-3)

TasP

WHO, 2012 (Recs 5)

ART adherence?

ARV resistance?

  • Real-world TasPeffectiveness in discordant couples?


Cvct scale up in government clinics

CVCT scale-up in government clinics

HIV prevalence, 15-49 year olds (DHS)


Impact of cvct on hiv t ransmission in a real world setting

Impact of CVCT on HIV transmission in a real-world setting

82% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)

Cost of preventing one HIV infection with CVCT in Zambia

$392

69% reduction in transmission after CVCT

RR 0.3 (95% CI 0.2-0.6)


Kristin m wall phd kmwall emory department of epidemiology

Impact of CVCT on HIV transmission in a real-world setting

82% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)


Kristin m wall phd kmwall emory department of epidemiology

Teasing apart the effects of CVCT and TasP

73% reduction in transmission after CVCT

RR 0.3 (0.1-0.6)

$666 to prevent one HIV infection

83% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)


Conclusions

Conclusions

CVCT is effective in a real-world setting

  • Irrespective of preceding therapeutic ART use

    • 70-80% reduction in HIV incidence, $400-$700 per infection averted

      TasP is not as effective in real-world settings as in a trial among serodiscordant couples who:

  • Have NOT been tested and counseled together

    • 30% reduction among those on therapeutic ART


Future questions art adherence

Future Questions: ART Adherence?

How much can retention and adherence improve when ART patients are counseled with their HIV- spouses?

  • ART NON-adherence: 40%1-2

  • ART attrition at 1 year: ¼3-4

1. Sasaki et al, An ClinMicAntimicro, 2012; 2. Birbeck, AJTMH 2009; 3. Scott et al, BMC Pub Health 2014; 4. Fox et al, TMIH, 2010


Future questions arv resistance

Future Questions: ARV Resistance?

Were ARV resistant viruses transmitted?

  • ARV resistance:1-2

    • 5-6% of ART naïve

      1. Price et al 2011; 2; Hamerset al, JAIDS, 2010

http://hivdb.stanford.edu/surveillance/map/


Recommendations

Recommendations

CVCT should be promoted and provided in all settings that offer HIV testing (WHO 2012 Recommendations 1-3 of Couples’ HIV Counseling Guidelines), including:

  • Antenatal clinics

  • PITC

  • Community-based VCT

  • Household VCT

    CVCT should be a priority in ART clinics(WHO 2012 Recommendation 4 of Couples’ HIV Counseling Guidelines)

    Resource allocation models should include CVCT and TasP

  • Using real-world estimates of effectiveness


Acknowledgements

Acknowledgements

Rwanda Zambia HIV Research Group (RZHRG) Contributors

Mubiana Inambao

M. KakunguSimpungwe Rachel Parker

Joseph Abdallah

Nuri Ahmed

William Kilembe

Amanda Tichacek

ElwynChomba

Gordon Streeb

Susan Allen

Arise—Enhancing HIV Prevention Programs for At-Risk Populations

IbouThior

Julie Pulerwitz

Zambian Ministry of Health & District Health Management Team

CVCT Clients & Clinic Staff


Kristin m wall phd kmwall emory department of epidemiology

Support for this project was provided by the Canadian Government through PATH and the Department of Foreign Affairs Trade and Development. The views expressed by the authors do not necessarily reflect the views of PATH, the Canadian Government or the Department of Foreign Affairs Trade and Development. This document was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.


Other rzhrg posters presentations supported by path arise

Other RZHRG posters/presentations supported by PATH-Arise

Arise Satellite Session, Thursday July 24th, 18:30-20:30 in Plenary 3

Posters

  • TUPE167

  • TUPE368

  • WEPE 435

  • WEPE 206

    Oral poster

  • THAC0504

    Oral abstract

  • THPDE0104


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