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Continuum of Care
HIV/AIDS Treatment Cascade
Presenter:
Arismendi A. Jimenez, MD
Vice President, Global Capacity Building
Cicatelli Associates Inc.
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Disclosure
The following people have no relevant financial, professional or personal relationships to disclose:
Faculty:
Arismendi A. Jimenez, MD
CNE Program Planner(s):
Melanie Steilen, RN, BSN, ACRN
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC
CNE Program Reviewer:
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC
There are no commercial supporters of this activity.
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LEARNING POINTS
• Review the continuum of care HIV/AIDS care
(treatment cascade)
• Discuss the implications of its findings and how it
affects the patients and public health
• Describe the impetus for action in each critical
junction of the cascade
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The history of the AIDS
global pandemic began in
illness, fear, and death
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IN TIME PROGRESS WAS MADE
• Public awareness
• Testing technology
• Treatment availability
• New medications
• Funding
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1 in 4 People with HIV are taking HIV medicine regularly and have
their virus under control.
1.2M People in the US are living with
HIV.
1 in 5 People with HIV
don't know they are infected, don't get HIV medical care, and can pass the virus onto others without knowing it
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Continuum of Engagement in Care
Source: U.S. Department of Health & Human Services Cheever 2007
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2011: The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection. Edward M. Gardner, ;Margaret P. McLees ;John F.
Steiner ;Carlos del Rio, and William J. Burman
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CONTINUUM OF CARE HIV/AIDS TREATMENT CASCADE (CDC)
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WHY IS THE HIV CARE CONTINUUM
IMPORTANT?
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FAILURES • Late diagnosis
• Non linkage
• Flawed linkage
• Insufficient ART
• Non ART Adherence
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20% unaware of their HIV
status.
Many of which are acutely infected
account for most of the new infections
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USING MARKS MODEL AND 2008 CDC DATA
ESTIMATING IMPACT OF KNOWLEDGE OF HIV INFECTION
ON SEXUAL TRANSMISSION OF NEW HIV INFECTIONS
~25% Unaware of
Infection
~75% Aware of Infection
~54 % of New
Infections
~46% of New Infections
Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50
Knowledge of HIV Infection New HIV Infections
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• Basic risk of transmission
• when the person is unaware of HIV Status 3 times more risky (Marks, et al; 2006)
• 26 times more risky if the person is in the acute state of infection. (Hollingworth, et al; 2008)
TOWERS OF RISK
0
5
10
15
20
25
30
Basic Risk Unaware Acute Infection
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DURING THE ACUTE STAGE
A person is between
100 and 3,000 times
more infectious than
persons in the later
stages of HIV infection
1. Kahn JO, et al 1998; 2. Quinn TC, et al 2000 3. Jacquez JA, et al 1994
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HIV SCREENING CAN BE IMPROVED…
Potential AIDS Defining Event
Number HIV Screening Rate (%)
Burkit Or Immunoblastic Lymphoma Or Primary Lymphoma Brain 2980 3.0
Encephalopathy 2066 5.0
Invasive Cervical Cancer 958 4.4
Candidiasis Of Bronchi, Trachea, Lung , Esophagous 542 7.0
Histoplasmosis, Disseminated, Extra pulmonary 370 2.2
Wasting/ cachexia 350 4.3
PNEUMOSISTIS CARINII PNEUMONIA 48 10.4
KAPOSI SARCOMA 35 8.6
Source: SAY YES TO THE TEST. New York State Department Of Health 4 / 13 Compiled from administrative claims data from 8 US plans national sample of commercially insured patients who where screened
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Unsafe sexual Behavior is reduced substantially
after people become aware they are HIV Positive
Overall reduction in
unsafe sex
Reduction in unsafe sex
(amongst sero-discordant
partners)
Say Yes to the Test, NYS Department of Health 4/13
53% Reduction
68% Reduction
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EARLY DETECTION AREAS OF NEED
• Expanding Testing Programs
– Specialty care practices
– Non traditional settings
– Pharmacy based testing initiatives
• Reduction Of Stigma
– Offering Testing Routinely
– Improve screening of early HIV infection
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LINKAGE TO CARE
AND EARLIER TREATMENT
• HPTN 052 trial: 96% reduction in HIV transmission
• 41% reduction in clinical events when treatment
started earlier
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COMMUNITY VIRAL LOAD
HIV
HIV
HIV
NO HIV TREATMENT MEANS: INCREASE INDIVIDUAL VIRAL LOAD
AND WITH THAT ALSO INCREASED COMMUNITY VIRAL LOAD
Individual Community
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San Francisco
24 November 2010 NAT Treatment as Prevention Das-Douglas, CROI 2010, abstract #33
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Why help in Linking people to Treatment:
– Lowering the amount of virus can keep a person with
HIV healthy longer.
– Keeping the virus under control with medicines greatly
lowers the chances of passing HIV.
– The number of people with HIV who get AIDS has
decreased. Still, more than 16,000 people with AIDS
die each year.
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6.4 6.6 6.8
7 7.2 7.4 7.6 7.8
8 8.2 8.4
Life expectancy no
HIV
HIV positive no early Dx &
Tx
Positive early Dx & Tx
Series 1
Fumiyo Nakagawa UCL Medical School, 2011
British study of Life expectancy of HIV-positives
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Thinking of Treatment as Prevention:
Improving testing and linkage to care
Suthar et al, Plos Med 2013 [Accepted] Global Update on HIV treatment, WHO, 2013
• Partner and couples testing; Community testing; Self-testing; Combination testing; linking to care
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– Married for 29 years, 3 children, public school teacher; husband and her
active in their community.
– Non-smoker; no known history of substance use.
– Felt sick with severe and persistent cough and difficulty breathing. With her
physician office closed, Anne went to the Emergency Department of her local
office where she received antibiotics and was kept overnight for observation
– The next morning her condition was still declining. A bronchoscopy reveal
Pneumocystis jiroveci. That triggered her physician to test her for HIV. The
result was positive
– Despite rapid initiation of appropriate treatments Anne’s condition continued
to decline and she died 2 days later. Post mortem lab results showed 21 CD4
cells and a viral load of 240,000 copies
MEET ANNE:
DID NOT APPEAR TO BE AT RISK FOR HIV
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AT LEAST 18 TIMES OVER MANY YEARS, ANNE COULD HAVE BEEN TESTED BUT WASN’T
* Hypothetical patient profile
Source: SAY YES TO THE TEST. New York State Department Of Health 4 / 13
*
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Video Review:
Treatment Cascade
HIV-free Generation Campaign
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Vision for the National HIV/AIDS
Strategy
The United States will become a place where
new HIV infections are rare and when they do
occur, every person regardless of age, gender,
race/ethnicity, sexual orientation, gender identity
or socio-economic circumstance, will have
unfettered access to high quality, life-extending
care, free from stigma and discrimination
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Thanks for your attention
Now…Let’s Roll !