prep may cause a revolution in hiv prevention: time to get...
TRANSCRIPT
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PrEP May Cause a Revolution in HIV Prevention: Time to Get Ready
Thomas J. Coates PhD Michael and Sue Steinberg Professor of Global AIDS Research
David Geffen School of MedicineUniversity of California, Los Angeles, USA
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A New Team of Two in Charge of HIV Prevention
Photo Courtesy of Bernie Branson - CDC
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MSM: Reduce Risks for
A-A and for Stimulant-
UsersIn progress
MSM: Reduce Risks for
A-A and for Stimulant-
UsersIn progress
Reduce Risk for
Vulnerable Women
In progress
Reduce Risk for
Vulnerable Women
In progress
Adolescent Risk
Reduction PrEP andBehaviorHPTN 060
Adolescent Risk
Reduction PrEP andBehaviorHPTN 060
Restore mucosal Integrity
MSM & WomenHPTN 039
Restore mucosal Integrity
MSM & WomenHPTN 039
Improve education
and access to care for all
HPTN 043
Improve education
and access to care for all
HPTN 043
EffectiveIDU
Treatment w/ Bupren/Nalox
HPTN 058
EffectiveIDU
Treatment w/ Bupren/Nalox
HPTN 058
ART to Reduce VL and protect
PartnersHPTN 052
ART to Reduce VL and protect
PartnersHPTN 052
Highly ActiveHIV
Prevention
Highly ActiveHIV
Prevention
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The 9 Best Things in HIV Prevention
1. Demonstrations that HIV prevention is possible and requires radical, not subtle, behavioral change
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Progress is Possible!
Not simpleNot subtleNot simplistic and usually multisectoralNo magic bulletBut change has happenedWe have an idea of what made it happe
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The 10 Best Things in HIV Prevention
1. Demonstrations that HIV prevention is possible and requires radical, not subtle, behavioral change
2. Knowledge of what does not work3. The male and female condom4. Other behavioral options—delay, reduction in partner number5. The HIV test—given to individuals, couples, families,
communities6. Prevention of mother-to-child transmission using anti-HIV
treatment7. Access to clean needles and syringes for drug users; drug
treatment; substitution therapy for drug use8. Male circumcision 9. Treatment for HIV (we think)10. Pre-exposure prophylaxis (we hope)
v
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The 3 Worst Things in HIV Prevention
1. Unparalleled impediments2. Driven by ideology3. Lack of preparation for
innovation
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See also http://www.avac.org/timeline-website/index.htm
Clinical Trials of Biomedical Prevention Strategies: 2006 and Beyond
2006 2008 2009 20102007 2011++
Vaccine –VRC PAVE 100
Male Circumcision –Susceptibility
Microbicides –Carraguard
Vaccine –Merck Adeno x2STEP/Phambili
Female Barrier Diaphragm
Male Circumcision –Infectiousness
Microbicides• BG/Pro2000
•Pro2000
Oral PrEP –IDU/Thai
HSV-2 Treatment –Infectiousness
HSV-2 Treatment –
Susceptibility
Oral PrEP• Heterosexual
(Botswana)
IndexPartner
Treatment (HPTN 052)
Vaccine –Thai
Prime/Boost
Community VCT and HIV
Support
Oral PrEP –West Africa
Microbicides –CS-1CS-2
Vaginal & OralPrEP (VOICE)
Oral PrEP• Serodisc(Partners)
Microbicides• TDF/PMPA (CAPRISA)
Oral PrEP• Heterosexual
(FemPrEP)
Oral PrEP – MSM USA Safety
Oral PrEP –MSM
(iPrEx)
Vaccine –HVTN 505
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Getting Ready for the Revolution Issue #1: Context and Messaging
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Holistic Approach to Prevention
Scheer et al, STI, 2009
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Interventions to Prevent HIV
HIV+ HIV-Newly HIV+
↓ exposure↓ susceptibility
↓ exposing others↓ infectiousness
↑ Counseling and Testing for HIV
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ART to Prevent Sexual Transmission of HIV
Pre-exposure Prophylaxis (PREP)-oral -topical-parenteral
Post-exposure prophylaxis (nPEP)USPH Guidelines 2003
Treatment of the infected person (index case)-observational results-HPTN 052/ACTG5245
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Getting Ready for the Revolution Context and Messaging
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Focus, Clarity of Goals, Precise Outcomes, Clear Management
CT for HIV
PrEP PMTCT M Circ
CT for HIV CT for HIV
Tx for HIV
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Implications of the New FrameworkRange of Behaviors Is of Interest
Testing and retestingCare-seeking
And barriers to careAdherence to medicationsActions to avoid spreading HIVDisclosure
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Getting Ready for the Revolution
Issue #3: Will HIV Prevention Be An
Indication for Use?
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Getting Ready for the Revolution Issue #4:
Getting PrEP to the Right People
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Get the Simple Things Right
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What About the Domestic Epidemic?
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HIV Incidence by Frequency of Stimulant Use, EXPLORE
5%20%75%
% of cohort
6.43.41.6
HIV incidence
12%32%56%
% of infections
Weekly or moreLess than weeklyNone
Frequency of use
Overall Seroincidence 2.1/100 p-yrs
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What About the Domestic Epidemic?
Source: http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/prevalence.htm
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HPTN 061: Feasibility Study of a Community-Based, Multi-component HIV Prevention Intervention for Black MSM
(in preparation for a community-randomized efficacy trial)
KENNETH H. MAYER M.D. and BERYL KOBLIN PhD
SWG Presentation May 19,2008
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896.7 million
46.8 million
HIV infections : the World, Africa & South Africa
13.74%
0.72%
Population HIV Infections
22.5 million
33.2 million
5.7 million
6.5 billion
68%
17%
UNAIDS 2007 data
>100,000 new infections per year
2.5 million new infections per year
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4 m people receiving ART by end of 2008
6.7m people need treatment and are in danger of losing their lives
2.7m became infected in 2007Only 1m placed on ART in 2007
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Getting Ready for the Revolution Issue #5:
Side effects and disinhibition
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Getting Ready for the Revolution Issue #6:
We Need to Plan the Follow-on Studies Now
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Getting Ready for the Revolution Issue #7:
Getting the Advantages of Medicalization of Prevention but
Leaving the Baggage Behind
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Getting Ready for the Revolution Issue #8:
ASOs and Financing