HIV Testing and Treatment: The Magnitude of the Impact

1. HIV Testing and Treatment:The Magnitude of the Impact Rochelle P. Walensky, MD, MPH Associate Professor of Medicine Harvard Medical School Division of Infectious Diseases Massachusetts General Hospital Brigham and Women’s Hospital Supported by NIAID, NIMH, and CDC

2. Overview • Treatment successes in HIV/AIDS • New WHO HIV treatment guidelines • When to initiate antiretroviral therapy • HIV screening • Impact of alternative PEPfAR scale-up strategies • PEPfAR in the context of maternal/child health

3. HIV Treatment is Very Effective: Survival Gains for Disease Interventions Walensky et al. JID, 2006

4. November 2009

5. The proposed changes • Replacement of stavudine with tenofovir • Increased number of sequential ART regimens • Earlier ART initiation at CD4 <350/µl instead of <200/µl

6. “When to Start” StrategiesImpact over the next 5 years (South Africa) OI: opportunistic infection ( ): denotes fewer ODs and deaths with ART at <350/μl Walensky et al. Ann Int Med, 2009

7. When is Antiretroviral Therapy Started? • Review of data from 2003-2005 from 42 countries, 176 sites, n=33,008 • Since 2000, CD4 at initiation in developed countries stable at about 175 cells/µl, increasing in Sub-Saharan Africa from 50  100 cells/µl. Late! Egger M, 14th CROI, Los Angeles 2007, #62.

8. When is Antiretroviral Therapy Started? • Review of data from 2003-2005 from 42 countries, 176 sites, n=33,008 • Since 2000, CD4 at initiation in developed countries stable at about 175 cells/µl, increasing in Sub-Saharan Africa from 50  100 cells/µl. Egger M, 14th CROI, Los Angeles 2007, #62.

9. Percent HIV-infected adults who were tested and received result WHO: http://who.int/hiv/pub/towards_universal_access_report_2008.pdf

10. HIV Screening 2 Outpatient Depts: Durban, South Africa 2008 HIV Testing 2,775 No test/result: 71 Indeterminate: 6 HIV-negative 1,308 HIV-infected 1,467 54% HIV prevalence Bassett et al. AIDS 2010

11. How many start ART? HIV Tested HIV-infected CD4/results Eligible for ART Start ART 2,775 1,467 605 Failure to obtain CD4 368 154 (42%) Failure to start ART when eligible Median time to ART initiation: 100 days Bassett et al. AIDS 2010

12. High Rate of Mortality15% of HIV-infected cohort Bassett et al. AIDS 2010

13. High Rate of Mortality15% of HIV-infected cohort

14. ART Roll Out in South Africa:The impact of speed on survival To examine alternative ART rollout scenarios in South Africa and to forecast number of lives lost while awaiting therapy Walensky et al JID 2008

15. 4 Growth Scenarios Walensky et al JID 2008

16. Projected Deaths & Alive on ART: South Africa, 2007-2012 Walensky et al JID 2008

17. Projected Deaths and Patients Alive on ART: 2007-2012 Walensky et al JID 2008

18. Are HIV Testing &Treatment Cost-Effective in These Settings? • Routine HIV screening (South Africa) YES: $1,940/YLS for annual screening compared to screening every 5 years (Walensky, CROI 2009) • ART in resource-limited settings (Côte d’Ivoire) YES: $590/YLS compared to no ART (Goldie, NEJM 2006) • ART initiation at CD4 <350/µl (South Africa) YES: $1,200/YLS ART at ≤350 cells/µl vs ART at CD4 ≤250 cells/µl (Walensky Ann Intern Med 2009)

19. PEPfAR & Maternal/Child Health • HIV testing, access to care, treatment and maternal/child health are linked at the core • Allows for prevention of mother to child HIV transmission • Allows for safe breastfeeding in lieu of formula feeding with potentially contaminated water • Prevents orphan-associated mortality • 10X increase risk of death

20. PEPfAR & Maternal/Child Health WHO: http://who.int/hiv/pub/towards_universal_access_report_2008.pdf

21. Conclusions • Life saving benefits of ART in HIV disease are greater than for virtually any other adult disease • Globally, these benefits can be increased by: • Increasing HIV testing and diagnosis • Increasing access to earlier ART • Making better drugs available • HIV testing and treatment are very cost-effective • HIV testing and treatment form the foundation for maternal/child health in areas of high HIV prevalence

23. Results:Percent ART Need Met by Year Rapid Moderate Constant % ART Need Met Zero Year Walensky et al. JID 2008

24. Proportion Alive at 5 Years Earlier ART Deferred ART No treatment Walensky et al. Ann Int Med 2009

25. AIDS Survival by Era

26. “When to Start” StrategiesImpact over the next 5 years (South Africa) OI: opportunistic infection ( ): denotes fewer ODs and deaths with ART at <350/μl

27. CD4 count within 90 days HIV-infected 1,467 Yes 607 No 862 59% no CD4 within 90 days 61% CD4<200/µl ART eligible at baseline CD4<200/μl 368 CD4≥200/μl 237 Bassett et al. AIDS 2010