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Summary of Track C: Epidemiology and Prevention Science. Audrey Pettifor, UNC Christopher Hurt, UNC Sheri Lippman , CAPS/UCSF Albert Liu, SFDPH Sinead Delany- Moretlwe , WRHI Nora Rosenberg, UNC. The Track C Team. Key Themes and Overview. We have effective tools

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summary of track c epidemiology and prevention science

Summary of Track C: Epidemiology and Prevention Science

Audrey Pettifor, UNC

Christopher Hurt, UNC

Sheri Lippman, CAPS/UCSF

Albert Liu, SFDPH

Sinead Delany-Moretlwe, WRHI

Nora Rosenberg, UNC

key themes and overview
Key Themes and Overview
  • We have effective tools
  • Given limited resources, how do we deliver interventions to maximize efficiency and effectiveness so we can “Get to Zero”.
    • Who to target?
      • Don’t know how interventions work in some populations (IDU)
    • What intervention(s) to use? What combination?
    • How to deliver to achieve maximum coverage and impact?
slide7

MSM

(Prejean et al., 2011)

most people living with hiv will live where the wealth is concentrated
Most people living with HIV will live where the wealth is concentrated

600 big cities in the world in 2025:

25% of the population

60% of the global wealth

2 of every 3 people living with HIV

will be living in urban areas by 2030

Source: McKinsey Institute, UNAIDS 2012

Schwartlander.

populations at high risk within generalized epidemics
Populations at high risk within generalized epidemics
  • MSM
  • IDU
  • Sex Workers
  • Adolescents
  • Aging Populations
  • Transgender Persons
  • Discordant Couples
slide10
4.8 million young people aged 15 – 24 years are living with HIV.3 million (two out of every three) are girls

Note: Global summary in title from UNAIDS, Together We Will End AIDS, 2012

map of hiv prevalence among female sex workers in low income and middle income countries 2007 2011

Pooled Odds Ratio for HIV infection among female sex workers compared to other women of reproductive age

13.5 (95% CI 10.0-18.1)

Map of HIV prevalence among female sex workers in low-income and middle-income countries, 2007-2011

Baral/Kerrigan et al.

THAC0501

new cross sectional measures of incidence
New cross-sectional measures of incidence

≤ 200 cells / ul

CD4 cell count

Stop

> 200 cells / ul

  • Development of assays (antibody and molecular or “HIV diversity assays”)
  • Statistical modeling approaches
  • Hybrids (lab + modeling)
  • Incidence estimates obtained using the multi-assay algorithm

≥ 1.0 OD-n

BED CEIA

Stop

< 1.0 OD-n

≥ 80%

Avidity

Stop

< 80%

≤ 400 copies/ ml

HIV viral load

Stop

> 400 copies / ml

Classified as recently infected

O. Laeyendecker

MOAC0203

slide13

What is the right intervention(s) to use for the population(s) targeted and how do we achieve maximal impact?

slide14

Treatment of STIs

Male circumcision

Grosskurth H, Lancet 2000

Auvert B, PloS Med 2005

Gray R, Lancet 2007

Bailey R, Lancet 2007

Male & female condoms

Structural /Social

HIV

PREVENTION combined interventions

HIV Counselling and Testing

PMTCT

Coates T, Lancet 2000

Behavioural Intervention

Harm Reducation/Needle exchange

the effects of mc are sustained
The effects of MC are sustained
  • The protective effect of MMC was sustained at 65% 66 months post intervention

Bailey R. TUAC0402

option b benefits
Option B+ Benefits

Source: UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012

harm reduction
Harm reduction
  • Harm reduction is working. In Amsterdam unsafe injections down and incidence declining(Grady MOAC0401)
  • In Vietnam, IDUs account for 75% of all new infections. RCT of sexual risk reduction and needle-sharing intervention, needle sharing decreased from 14% at baseline to 3% at 3 months, and exhibited a durable effect (Go THAC0404).
  • Modeling results of combination IDU interventions in particular high coverage sterile syringe distribution (Marshall FRLBC05)
treatment as prevention
Treatment as Prevention
  • Mathematical models can help guide decision-making (Granich, Kessler, Stover, Gweshe).
  • Targeting all HIV-infected persons is always the most effective strategy
  • The challenge will be determining which populations to target in the short-term given limited resources:
    • What CD4 level? (200-350? 350-500? >500?)
    • Which patients? (pregnant women? discordant couples? TB patients? IDUs? all?)
  • This will depend on the epidemic context, current service delivery environment , and resources available.
why is hiv transmission continuing
Why is HIV transmission continuing?

And…

And…

in 2010 only 15-25% of MSM had an HIV test

A Brown. THAC0201

expanding testing
Expanding Testing
  • Home based testing works (Carballo-DieguezTUPDC0304)
  • In South Africa by June 2011 a record 13,269,746 HIV tests were conducted. 16% tested positive of whom 48% had CD4 counts above 350 (Mbengashe THPDE0304)
  • Peer testing of IDU in Thailand (Ti THAC0405)
the treatment cascade keeping people in care
The treatment cascade: keeping people in care
  • Success in finding those lost to care in NYC using programs to trace patients out of care (Udeagu MOPDC0306)
  • Programs with tracing had lower LTFU, mortality and higher retention (McMahan MOAC0302)
  • Community distribution of ART in Tanzania, Uganda and Zambia reduced LTFU (Koole MOAC0305)
prep like art works when taken
PrEP (like ART) works when taken

There is a clear dose-response

between evidence of PrEP use & efficacy

Baeten et al N Engl Med 2012

Grant et al N Engl J Med 2010

Van Damme et al N Engl J Med 2012

Thigpen et al N Engl J Med 2012

MugoTUPL0102

why do we need prep demonstration projects
Why do we need PrEP demonstration projects?
  • Will MSM want PrEP?
  • How will MSM use PrEP?
  • How will sexual practices change?
  • Where are PrEP delivery systems best located?
  • WillPrEP be safe in the “real world”?

Cohen AIDS 2012

the hiv investment framework
The HIV Investment Framework

Reduce Risk

Reduce likelihood of transmission

Reduce mortality and morbidity

  • Condoms
  • Male circumcision
  • PMTCT
  • Treatment
  • Key populations
  • Behavior change

BASIC PROGRAMME ACTIVITIES

CRITICAL ENABLERS

SYNERGIES

Adapted from: SchwartlanderB, et al. The Lancet, 377 (9782), 2011

slide26

Lower income (<$20k)

OR, 3.42 (1.94-6.01)

Undiagnosed HIV

OR, 6.38 (4.33-9.39)

HIV

Detection

Diagnosed HIV+

OR, 3.00 (2.06-4.40)

Health insurance

coverage

OR,0.47 (0.29-0.77)

Healthcare visits

OR, 0.61 (0.42-0.90)

ART utilization/ access

OR, 0.56 (0.41-0.76)

>200 CD4

cells/mm3 before

ART initiation

OR, 0.40 (0.26-0.62)

STRUCTURAL FACTORS AFFECT RETENTION IN CARE

ART adherence

OR, 0.50 (0.33-0.76)

HIV suppression

OR, 0.51 (0.31-0.83)

Viral Suppression

(Millett, 2012)

cumulative impacts of parental hiv aids abuse and hunger on child transactional sex
Cumulative impacts of parental HIV/AIDS, abuse and hunger on child transactional sex

Cluver. WEAC0102

modeling community empowerment interventions on infections averted in fsw
Modeling Community Empowerment Interventions on Infections averted in FSW
  • Combined ART and empowerment intervention may avert 16 - 40% of infections among sex workers across epidemics, assuming equal access to HIV testing and treatment
  • Empowerment intervention could enable ART access among sex workers through a community-based outreach and mobilization approach

Cumulative infections averted among FSWs and adults with scale-up of empowerment (2012-16)

A. Wirtz

THAC0502

slide29

Treatment of STIs

Male circumcision

Microbicides

for women

Harm Reduction/Needle exchange

Grosskurth H, Lancet 2000

Auvert B, PloS Med 2005

Gray R, Lancet 2007

Bailey R, Lancet 2007

Abdool Karim Q, Science 2010

Male & female condoms

HIV

PREVENTION combined interventions

STRUCTURAL

HIV Counselling and Testing

PMTCT

Oral pre-exposure prophylaxis

Coates T, Lancet 2000

Grant R, NEJM 2010 (MSM)

Baeten J , NEJM 2012 (couples)

Thigpen, NEJM, 2012 (Heterosexuals)

Behavioural Intervention

Post Exposure

prophylaxis (PEP)

Treatment for prevention

Donnell D, Lancet 2010

Cohen M, NEJM 2011

Scheckter M, 2002

MugoTUPL0102