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How well are we doing in preventing HIV and how can we do better?

How well are we doing in preventing HIV and how can we do better?. Peter Piot Institute for Global Health Global HIV/AIDS vaccine enterprise. PREVENTION WORKS BUT. Community mobilisation, Thailand’s 100% Condom Program. Pilot in Ratchaburi province. Implementation on a national scale.

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How well are we doing in preventing HIV and how can we do better?

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  1. How well are we doing in preventing HIV and how can we do better? Peter Piot Institute for Global Health Global HIV/AIDS vaccine enterprise

  2. PREVENTION WORKSBUT...

  3. Community mobilisation, Thailand’s 100% Condom Program Pilot in Ratchaburi province Implementation on a national scale Proportion of condom use with Reported STD nationally recent clients Source:UNAIDS Case Study: Evaluation of the 100% Condom Programme in Thailand, 2000. http://data.unaids.org/Publications/IRC-pub01/JC275-100pCondom_en.pdf

  4. HIV Prevalence Declines in Pregnant Women Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS.  July 2008.

  5. Behavioural change, impact in urban and semi-urban Zimbabwe M1: assuming behavioural change, better fit to surveillance data Natural decline in incidence ~1990 Accelerated decline in incidence, due to behaviour change ~2000 M0: without behavioural change Source: Hallett TB, et al. Epidemics 2009;1(2):108-117

  6. Basic reproductive rate R0 = β c D Transmission probability Mean duration of infection Condom use ART Microbicides PrEP PMTCT Circumcision Clean needles VCT ART Mean number of contacts VCT Behavioural change Substitution therapy

  7. Effectiveness of condoms in preventing STIs including HIV This review of prospective studies published 2000-2004 identified evidence that consistent condom use is associated with reduced transmission in HIV Source: Holmes KK, et al. Bull World Health Organ. 2004;82(6):454-61.

  8. 40 600 000 35 500 000 30 400 000 25 300 000 20 15 200 000 10 100 000 5 0 0 2004 2005 2006 2007 Year Number of HIV-positive pregnant women receiving anti-retrovirals % of HIV-positive pregnant women receiving anti-retrovirals Number and percentage of HIV-positive pregnant women receiving antiretroviral prophylaxis Source: UNAIDS, UNICEF & WHO, 2008; data provided by countries.

  9. Reduction of acquisition risk after male circumcision (A) South Africa (B) Kenya (C) Uganda Cumulative probabilities of HIV detection Cumulative sero-incidence Infection-Free Probability Source: (A) Auvert B, et al. PLoS Med 2005;2(11): e298, (B) Bailey RC, et al. Lancet 2007; 369:643–656 and (C)Gray RH, et al. Lancet 2007; 369:657–666.

  10. RCT: Treatment of STIs Source:Ronald Gray, Plenary lecture - Biomedical HIV Prevention Trials (A Sisyphean Task). Cape Town, IAS conference. 19-22July 2009. http://www.ias2009.org/pag/

  11. Decriminalisation

  12. Concurrency • Strong case in modelling for concurrency as a determinant of HIV in southern Africa • BUT • Empirical evidence is lacking • Polygyny protective • More research needed on sexual networks • Standard definitions needed for concurrency • What is the intervention?

  13. Population impact of treatment as prevention Time trends resulting from application of universal voluntary HIV testing and immediate ART strategy for people who test HIV positive, in combination with other adult prevention interventions that reduce incidence by 40% Source: Granich RM, et al. Lancet 2009; 373: 48–57.

  14. NO MAGIC BULLET

  15. Combination prevention Source:Coates TJ, et al. Lancet 2008; 372:669–84.

  16. Interaction of circumcision interventions with existing behaviour change programmes Projected effect of different prevention interventions on HIV incidence Source: Hallett TB, et al. PLoS ONE 2008;3(5): e2212

  17. Effectiveness /efficacy and controversies Rates of HIV infection during typical and perfect use Source:Cates W. Technical advances in HIV prevention, in HIV/AIDS Annual Update 2006. In: Phair JP, ed. Clinical Care Options, 2006.

  18. Know your epidemic • Cambodia, 1988-2004 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Male clients Sex workers Wife from husband Husband from wife Mother to child Number of new HIV infections by route of transmission Source: Peerapatanapokin and Brown, using Asia Epidemic Model

  19. Know your epidemicLithuania 2004 2008 Proportion of HIV diagnosed cases by transmission category Source: Strujeva O , et al. Poster CDC079 – HIV infection trends in Lithuania in 2004 – 2008. Cape Town, IAS conference. 19-22July 2009. http://www.ias2009.org/pag/

  20. HIV Prevention Research Time-line of Expected Efficacy Trial Results (AVAC) Source: www.avac.org/timeline-website/

  21. AIDS IS NOT OVER

  22. The prevention gap Percentage of population groups most at risk with access to prevention services, 2008 Source: WHO/UNICEF/UNAIDS. Towards Universal Access. Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009.

  23. Treatment Action Campaign (TAC), South Africa

  24. Preventive expenditure for men who have sex with men and % of AIDS cases among them • Source: SIDALAC/UNAIDS. 2001

  25. Cost Effectiveness

  26. The long term view • Stop generic response to heterogeneous problem • Start structural interventions NOW • Invest in professionals and institutions • Donor indicators and incentives focus on long term impact • Maximise programme efficiency • R&D

  27. Combination treatment • + • Combination prevention • + Vaccine???

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