treatment as prevention · julio montaner md, frcpc, fccp director, bc-centre for excellence on...
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British Columbia Centre for Excellence in HIV/AIDS
Julio Montaner MD, FRCPC, FCCPDirector, BC-Centre for Excellence on HIV/AIDS, Providence Health Care
Professor of Medicine and Chair, AIDS Research, University of British ColumbiaPresident, International AIDS Society
WHO, Geneva, Nov 2009
Treatment as Prevention:HAART Expansion - A Powerful Strategy to Reduce
AIDS Morbidity and Mortality and HIV Incidence
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Effect of HAART on HIV Transmission
HAART stops HIV replication
↓
HIV levels fall to undetectable in
blood as well as sexual fluids
↓
Sharp reduction in HIV transmission
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Prevention Strategies
- Education- Change in behavoir- Harm reduction- New strategies/technology- Vaccines
Existing strategies have failed to contain the global HIV pandemic
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PERINATAL HIV TRANSMISSION AND MATERNAL VIRAL LOAD: CIHR - CTN CANADIAN PERINATAL HIV SURVEILLANCE PROGRAM (CPHSP)
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Discordant Couples
S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS. 2009 Jul 17;23(11):1397-404
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Discordant Couples
S Attia, M Egger, M Muller, M Zwahlen and N Lowa. AIDS. 2009 Jul 17;23(11):1397-404
Conclusion: Studies of heterosexual discordant couples observed no transmission in patients treated with ART and with viral load below 400 copies/ml, but data were compatible with
one transmission per 79 person-years.
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Anema et al Eur Jour of Inf Dis, 2009
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Anema et al Eur Jour of Inf Dis, 2009
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~ 80%
~ 20%
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To evaluate the relationship between “community plasma HIV RNA” and HIV incidence among injection drug users
Conducted within Vancouver’s DTES
Using two concomitant sister cohorts (VIDUS)
HIV+ IDUs
HIV- IDUs
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Whiskers represent 95% confidence intervals.
Community plasma HIV RNA levels in a cohort of injection drug users in Vancouver’s DTES
Wood et al, BMJ, May 16, 2009
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HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals.
HIV incidence in a cohort of injection drug users in Vancouver’s DTES
Wood et al, BMJ, May 16, 2009
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Community plasma HIV RNA levels and HIV incidence among two parallel cohorts of IDUs
HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals.
Wood et al, BMJ, May 16, 2009
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Wood et al, BMJ, May 16, 2009
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A Formidable Challenge
A Unique Opportunity
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Yea
Treat all Treat 30%
HIV prevalence
Montaner et al, Lancet 2006
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Treat 30%
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Treat all
Treat 30%
The Power of HAART: Demographic Model
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R Granich, C Gilks, C Dye, K De Cock, B Williams. The Lancet Nov 26th 2008
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New Data
Work in ProgressStrictly Confidential
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Prospectively Evaluate the Impact of HAART Expansion on AIDS Morbidity and Mortality and HIV Incidence in BC
Intervention Primary EndpointHAART Expansion HIV Incidence within medical guidelines at years 3 to 5
Secondary Endpoints:
MORBIDITY AND MORTALITY, CD4 COUNTS, HIV-1-RNA LEVELS,
RESISTANCE, ADVERSE EVENTS, SAFETY, ADHERENCE,
HOSPITALIZATIONS, RESOURCE UTILIZATION
STOP HIV & AIDSSTOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS*
* Supported through a five year Avant Garde Award by the National Institute for Drug Abuse (NIDA) at the NIH
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HIV Reportable
Modified from Montaner et al, Lancet, 2006
HIV Reportable
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HIV Reportable
Modified from Montaner et al, Lancet, 2006
Decrease in HIV new cases attributed to initial roll out of
HAART between 1996 and 1999, consistent with that seen in
Taiwan (JID, 2005)
HIV ReportableHIV Reportable
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HIV Reportable
Montaner et al, Work in Progress 2009
HIV ReportableHIV Reportable
Decrease in HIV new cases attributed to initial roll out of
HAART between 1996 and 1999, consistent with that seen in
Taiwan (JID, 2005)
January 2004
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January 2004
Note that the expansion of HAART here described occurred prior to the new 2008 IAS-USA
Guidelines, which were adopted in BC at the end of 2008
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Jan 2004
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January 2004
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0
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Highest pVL January 2004
“Average” pVL
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HAART has a substantial added preventive value
The magnitude of this effect is not yet fully characterized, and may well
vary in different settings
Seek and Treat among those who have a medical indication for
HAART cannot wait for the above to be resolved
Many lives will be saved and much insight will be gained from closely
monitoring a more “aggressive”roll out of HAART
Seek and Treat outside the area where treatment is medically
indicated remains a research question
However, current guidelines, if liberally applied, may leave relatively few
outside the “treatment envelope”
Seek and Treat will only be effective as part of a comprehensive
Combination Prevention strategy that includes strong HR protection
Treatment as Prevention:HAART Expansion - A Powerful Strategy to Reduce AIDS Morbidity and
Mortality and HIV Incidence
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All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time.
Bradford-Hill, A. 1965 The environment and disease: Association or Causation? Presidentaddress at January 14 meeting. Proceedings of the Royal Society of Medicine 163 (seriesB): 295-300.
A Statistician’s Opinion
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AIDS Nov 27th 2008, The EconomistDeploying the drugs used to treat AIDS may be the way to limit its spread
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Illustration by Peter Schrank
Thank you
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0
10
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January 2004
January 2004
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0
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30
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1997
1998
1999
2000
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2002
2003
2004
2005
2006
2007
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. 28,
200
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³ 50,000 10,000 - 49,999 3500 - 9999 500 - 3499 < 500
Highest pVL
January 2004
January 2004
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Combination prevention
Community Interventions
Biomedical Interventions
Structural Interventions
HIV testing and linkage
to care
Individual and small
group behavioral
interventions
HIV prevention
Adapted from T Coates
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Thank You
British Columbia British Columbia Centre for Excellence Centre for Excellence in HIV/AIDSin HIV/AIDS
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British Columbia Centre for Excellence in HIV/AIDS
STOP HIV & AIDSSTOP HIV & AIDS: Seek and Treat to Optimally Prevent HIV & AIDS
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R Hogg, E Wood, T Kerr, M Tyndall, A Levy, PR Harrigan, V Lima, A Anema, Pedro Cahn, Jose Esparza, Craig Mc Clure
ART Guidelines Panel, IAS - USABC-MoH
SPH FoundationPharmaceutical Industry
MSHRF, CIHR, NIDA and NIHH&W, Ottawa
Research Staff and Study Participants