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The strategic use of ARVs Treatment as Prevention

The strategic use of ARVs Treatment as Prevention. Professor Charles Gilks School of Population Health UQ HIV earlier treatment workshop Brisbane 15 March 2014. ARVs for prevention. Biological plausibility HIV is an infectious disease Clear gradation of viral load on infectivity

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The strategic use of ARVs Treatment as Prevention

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  1. The strategic use of ARVsTreatment as Prevention Professor Charles Gilks School of Population Health UQ HIV earlier treatment workshop Brisbane 15 March 2014

  2. ARVs for prevention • Biological plausibility • HIV is an infectious disease • Clear gradation of viral load on infectivity • PACTG 076 (1994): AZT prevents MTCT • TB control based on treatment • Global ART scale-up since 2001 • Massive achievements in starting ART • ARV prophylaxis for HIV prevention • Pregnant women in PMTCT programmes • Health-care workers access to PEP So why so long for strategic use for Prevention?

  3. The Test and Treat Model

  4. HIV Prevention Technologies Shown to Be Effective in Reducing HIV Incidence in Randomized Clinical Trials

  5. A framework to understand the epidemiological impact of cART to onward HIV transmission The HIV Modelling Consortium TasP Editorial Writing Group PLoS Medicine 2012 vol 9 e1001259

  6. Process Indicators for TasP • Median CD4 at ART initiation • ART coverage • Retention in care • adherence and viral suppression

  7. Focus - Know your epidemic: who is getting infected? Mode of Transmission Geographic Focus 6% 32% 41% Note also infants born with HIV/year (< 350: <3% ) 10% 94% of new infections 11% 27 provinces (1/3rd of provinces) cover 70% of new HIV infections 41%

  8. TasP global issues : ART eligibility policy Estimated millions of people eligible for ART in LMIC in 2011 1115232532 Recommended Since 2003 Recommended since 2010 “Test and treat” Incremental approach 2012 Ongoing systematic review of evidence (GRADE review) CD4 ≤ 200 CD4 ≤ 350 CD4 ≤ 350 + TasP CD4 ≤ 500 All HIV+ 5 3 4 1 2 ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM)

  9. TasP global issues : treatment gap to 2015

  10. Mean CD4 count at ART initiation is below 200 in Low and Middle-income Countries Lower middle-income Upper middle-income High-income come Low-income Mean CD4 count (cells/µl) (ccells/µells/µL) 2002 2009 2002 2009 2002 2009 2002 2009 Year of starting ART Estimates from random-effects model adjusted for age, sex and year of starting ART, 2002-2009 Source: Egger M. CROI 2012

  11. The ideal and the good Deploying the drugs used to treat AIDS may be the way to limit its spread Illustration by Peter Schrank Illustration by Peter Schrank From The Economist Nov 27th 2008

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