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Treatment as Prevention: Research, Policy, and Best Practices

Treatment as Prevention: Research, Policy, and Best Practices. Jennifer Hecht, MPH July 2012 International AIDS Conference, Washington DC. Concept of “ Treatment as Prevention ” (TAP). Treat people who are HIV+  suppresses viral load  reduce infectiousness

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Treatment as Prevention: Research, Policy, and Best Practices

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  1. Treatment as Prevention: Research, Policy, and Best Practices Jennifer Hecht, MPH July 2012 International AIDS Conference, Washington DC

  2. Concept of “Treatment as Prevention” (TAP) Treat people who are HIV+  suppresses viral load  reduce infectiousness • reduce likelihood of transmission • fewer new HIV cases (incidence) Relatively new strategy for prevention SAN FRANCISCO AIDS FOUNDATION

  3. 1 What’s the big deal about Treatment as Prevention? 2 Steps to achieving viral load suppression in order to reduce HIV incidence 3 Basic information about adherence Evidence-based interventions to address barriers to engagement in care and adherence 4 SAN FRANCISCO AIDS FOUNDATION

  4. 1 What’s the big deal about Treatment as Prevention? SAN FRANCISCO AIDS FOUNDATION

  5. Mathematical Model Source: Granich, Lancet 2009 • Granich model (2009): model for eliminating HIV transmission in South Africa by testing all adults and treating those who tested positive • Within 10 years, this strategy would dramatically reduce HIV incidence • Over time, it would be cost effective SAN FRANCISCO AIDS FOUNDATION

  6. Key randomized control trial • Early treatment of HIV+ partner in heterosexual serodiscordant couple reduced risk to HIV negative partner by 96% (HPTN 052) • Results released in 2011 Source: Cohen, N Engl J Med, 2011 SAN FRANCISCO AIDS FOUNDATION

  7. Community Viral Load (CVL) • Concept: the amount of virus in the community can be measured (and reduced through treatment to reduce population-level transmission) • San Francisco data suggests that reduction in CVL corresponds to a reduction in new HIV cases • Canada saw a decline in new infections as number of individuals on HAART increased Sources: Das, PLoS One, 2010 Montaner, The Lancet 2010 Kirk, CROI, 2011 SAN FRANCISCO AIDS FOUNDATION

  8. Clinical benefit from treatment Aging and HIV; clinical benefit to treatment Source: Kitahata, N Engl J Med, 2009 • NA-ACCORD project in US and Canada • Risk of death was significantly lower in individuals who start HIV medications earlier SAN FRANCISCO AIDS FOUNDATION

  9. Policy recommendations for treatment initiation Putting TAP in context: • International AIDS Society panel • recommendations change over time • Swiss statement (2008): Recent policy changes: • SFDPH recommends treating all people with HIV regardless of CD4 count (2010) • US releases National HIV/AIDS strategy (2010) • NYC DOH follows suit (2011) • CDC follows suit (2012) SAN FRANCISCO AIDS FOUNDATION

  10. # Steps to achieving viral load suppression in order to reduce HIV incidence SAN FRANCISCO AIDS FOUNDATION

  11. Treatment Cascade, Washington D.C SAN FRANCISCO AIDS FOUNDATION

  12. # Basic information about adherence SAN FRANCISCO AIDS FOUNDATION

  13. Brief Overview: Key points about adherence • Viral load decreases with increased adherence (up to 95%) • Facilitators of adherence include: having a regular routine, belief in effectiveness of treatment • Barriers include: depression, psychosocial factors, structural factors (ex medical mistrust, stigma)

  14. Many factors affect adherence Demographic: • Age (youth) • Race (nonwhite) Psychosocial: • Mental illness • Substance use • Perceived efficacy of treatment • Cultural beliefs about treatment • Stressful life events • Lack of social support • Fear of death Medical: • Meds not working • Side effects from meds • Regimen complexity • Memory problems • Physical health Structural: • Transportation • Lack of access to insurance or primary care • Food and nutrition • Medical mistrust • Low income • Marginal housing • Stigma Education: • Low health literacy Other: • Poor relationship with doc • Being newly diagnosed • Relationship with partner   

  15. # Evidence-based interventions to address engagement in care and adherence SAN FRANCISCO AIDS FOUNDATION

  16. Interventions: Engagement in care Engagement in care Source: www.effectiveinterventions.org • ARTAS is the only intervention shown to increase engagement in care in an RCT trial • Up to 5 one-on-one strengths-based case management sessions for people who are HIV+ and not in care SAN FRANCISCO AIDS FOUNDATION

  17. Interventions: Adherence Source: www.effectiveinterventions.org • Five interventions are CDC-approved • Project HEART • Social support intervention during the first 2 months of treatment; individual and two-person sessions • Pager messaging • Customized text message reminders • Peer support • Individual and group-level support • Partnership for Health • clinic-based; emphasize patient-provider relationship • SMART • Counseling for serodiscordant couples

  18. sfaf.org 1035 Market Street, Suite 400 | San Francisco, CA 94103 SAN FRANCISCO AIDS FOUNDATION

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