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From “ What If ” to “ What Now ”

From “ What If ” to “ What Now ” Perspectives on ARVs and the Future of Treatment and Prevention. Mitchell Warren Executive Director, AVAC IAS 2011, Rome. Timing is Everything. 2004 2007 2010 2011 . No magic bullet; need smart combinations. Treatment of STIs. Male circumcision.

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From “ What If ” to “ What Now ”

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  1. From “What If” to “What Now” Perspectives on ARVs and the Future of Treatment and Prevention Mitchell Warren Executive Director, AVAC IAS 2011, Rome

  2. Timing is Everything • 2004 • 2007 • 2010 • 2011

  3. No magic bullet; need smart combinations

  4. Treatment of STIs Male circumcision Microbicides for women Grosskurth H, Lancet 2000 Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Abdool Karim Q, Science 2010 Treatment for prevention Female Condoms Positive prevention - behavioral Felblum P, AIDS 2001 Donnell D, Lancet 2010 Cohen M, 2011 Fisher J, JAIDS 2004 COMBINATION HIV PREVENTION Male Condoms Brody S, NEJM 1996 HIV Counselling and Testing Pre-Exposure prophylaxis Oral PrEP for MSM Coates T, Lancet 2000 Grant R, NEJM 2010 Behavioural Intervention Post Exposure prophylaxis (PEP) Vaccines • Abstinence • Be Faithful Scheckter M, 2002 Rerks-Ngarm S, NEJM 2009 Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is focused on reducing sexual transmission

  5. Effect size (CI) Study Prime-boost Vaccine (Thai RV144) 31% (1, 51) 1% tenofovir gel (CAPRISA 004) 39% (6, 60) TDF/FTC oral-PrEP (iPrEx, Grant et al 2010) 44% (15, 63) Medical male circumcision (Orange Farm, Rakai, Kisumu) 57% (42, 68) TDF/FTC oral-PrEP (TDF2, CDC) 63% (22, 83) TDF oral-PrEP (Partners PrEP) 62% (34, 78) 73% (49, 85) TDF/FTC oral-PrEP (Partners PrEP) 96% (82, 99) Immediate ART for positive partners (HPTN052) 0% 10 20 30 40 50 60 70 80 90 100% Efficacy

  6. History Lessons A vaccine [or condom, or microbicide or tablet] that sits on the shelf is useless. Albert Sabin

  7. And an Old Challenge 8% Harm reduction for injection drug users 9% Condom access 10-12% Adults with access to HIV testing in Africa 11% Behavior change programs for men who have sex with men 16% Behavior change programs for commercial sex workers 33% Prevention of mother-to-child transmission 0% 40% 60% 80% 100% 20% • Can we deliver on the promise? • Global access to existing prevention options Source: UNICEF/UNAIDS/WHO 2009

  8. No magic bullet; need smart combinations • Corollary: Need smart researchers, policy makers, funders and advocates!

  9. No magic bullet; need smart combinations • It’s behaviour

  10. No magic bullet; need smart combinations • It’s behaviour • Adherence, adherence, adherence

  11. No magic bullet; need smart combinations • It’s behaviour • Adherence, adherence, adherence • Embrace the niche

  12. No magic bullet; need smart combinations • It’s behaviour • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence

  13. Pathway to Reversing the Epidemic Deliver today Male & Female Condoms Demonstrate today HIV incidence Medical Male Circumcision ARV Tx as Px Deliver soon ARV PrEP Develop for tomorrow ARV microbicide Partially effective vaccine highly effective vaccine Time

  14. No magic bullet; need smart combinations • It’s behaviour, stupid! • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence • Testing, testing, testing

  15. No magic bullet; need smart combinations • It’s behaviour, stupid! • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence • Testing, testing, testing • Watch our language

  16. An Evolving Lexicon • ART • ARV • Oral PrEP • PEP • Topical PrEP • Microbicides • Long-acting methods • TasP • TisP • T4P • TnT • TLC+

  17. No magic bullet; need smart combinations • It’s behaviour, stupid! • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence • Testing, testing, testing • Watch our language • Four questions

  18. Four Questions • Who needs what? • Who wants what? • Who gets what? • Who pays?

  19. No magic bullet; need smart combinations • It’s behaviour, stupid! • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence • Testing, testing, testing • Watch our language • Four questions • Money, money, money

  20. Money, Money, Money • “Science of Prioritization and the Primacy of Targeting” Ward Cates, personal communication, the day before yesterday • “Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends.” Towards an improved investment approach for an effective response to HIV/AIDS, Schwartländer B et al, Lancet, 3 June 2011 • “If one accepts the tenet that science should inform policy, then the scientific data are speaking loud and clear. Global policy-makers must seriously consider these new data in their priority-setting and decision-making.” AIDS: Let Science Inform Policy, Fauci AS, Science, 1 July 2011

  21. No magic bullet; need smart combinations • It’s behaviour, stupid! • Adherence, adherence, adherence • Embrace the niche • Strategize the sequence • Testing, testing, testing • Watch our language • Money, money, money • Four questions • Scientific data do not change the world—programmes and policies backed by civil society, donors, implementers and governments do

  22. Reading List, July 2011 • AIDS: Let Science Inform Policy, Fauci AS, Science, 1 July 2011 • Antiretroviral Prophylaxis: A Defining Moment in HIV Control, Abdool Karim SA and Abdool Karim Q, Lancet, 15 July 2011 • Towards an improved investment approach for an effective response to HIV/AIDS, Schwartländer B et al, Lancet, 3 June 2011 • We CAN End The Epidemic, www.endtheepidemic.org

  23. WITH URGENCY

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