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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. The Track C Team. Key Themes and Overview. We have effective tools

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Summary of Track C: Epidemiology and Prevention Science

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  1. 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

  2. The Track C Team

  3. 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?

  4. WHO TO TARGET?

  5. MSM (Prejean et al., 2011)

  6. 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.

  7. Populations at high risk within generalized epidemics • MSM • IDU • Sex Workers • Adolescents • Aging Populations • Transgender Persons • Discordant Couples

  8. 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

  9. 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

  10. 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

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

  12. 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

  13. The effects of MC are sustained • The protective effect of MMC was sustained at 65% 66 months post intervention Bailey R. TUAC0402

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

  15. 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)

  16. 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.

  17. Why is HIV transmission continuing? And… And… in 2010 only 15-25% of MSM had an HIV test A Brown. THAC0201

  18. 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)

  19. 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)

  20. 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

  21. 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

  22. PrEP knowledge, acceptability, and potential for risk compensation

  23. 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

  24. 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)

  25. Cumulative impacts of parental HIV/AIDS, abuse and hunger on child transactional sex Cluver. WEAC0102

  26. 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

  27. 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

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