Transcript Slide 1

ART for Prevention
From Evidence to Action
Wafaa El-Sadr, MD, MPH
ICAP-Columbia University
The Evidence is Here!
• Ecological data
• Observational studies in discordant couples
• Randomized clinical trial (HPTN 052)
Number of PLWH receiving ART in low- and middle-income
countries, by region, 2002–2009
UNAIDS, 2010
HIV Treatment Coverage in Low & Middle
Income Countries
WHO Towards Universal Access 2010
ART for Prevention
Enroll in Care
Test
Initiation
of ART
Testing
Treat
HIV Positive
Positive
Prevention
Adopt safer behaviors
Linkage
to care
Decrease in HIV
Transmission
Adherence
to ART
Maintain viral
suppression
ART for Treatment & Prevention
Enroll in Care
Test
Initiation
of ART
Testing
Treat
HIV Positive
Positive
Prevention
Adopt safer behaviors
Linkage
to care
Adherence
to ART
Maintain viral
suppression
• Decrease in HIV Transmission
• Optimal Treatment Outcomes
HIV Care Continuum
ART eligible
HIV
Diagnosis
Pre-ART
Monitoring and Retention
in Care
ART
Monitoring, Retention and
Adherence Support
HIV Testing and Knowledge of HIV Status-Kenya
16% knew they were
positive
56% never
tested
for HIV
28%
reported last
HIV-test
84% of HIV-infected adults
negative
did not know their status.
KAIS, 2008
Awareness of HIV Status Among Persons
with HIV and Estimates of Transmission-- US
~21%
Unaware of
Infection
~54 - 70%
of New
Infections
~75%
Aware of
Infection
~30 - 46%
of New
Infections
People Living with HIV/AIDS New HIV Infections Each
Marks, et al AIDS 2006
1,106,400
Year: ~56,000
Point of Entry into HIV care
ICAP-Supported Programs
VCT
PMTCT
PICT
TB/HIV
Other clinic referral/unknown
January 2010-March 2011
Advances in HIV Testing
• Home-based testing:
– Randomization of household members of HIV-infected patients to
home-based or clinic based VCT
– Household testing versus clinic VCT:
• 55.8% versus 10.9% OR: 10.4 (95% CI: 7.89-13.73; P<0.001)
• Community-based testing: Project Accept (HPTN 043)
– Community-randomized study (32 communities)
– Community-based plus clinic-based C&T versus clinic-based C&T
– Community-based plus clinic-based:
• Mean difference in proportion tested: 40.2% (95% CI: 15.8-64.7%, P=).019
• Detected four fold more HIV cases than clinic based (952 vs 265 (P=0.003))
• Self testing:
– Feasibility study in Malawi
– Of 260 who opted for self-test, 99.2% accurate test
– 100% indicated would recommend to friends and family
Lugada et al. JAIDS, 2010
Sweat et al, Lancet 2011
Choko et al, CROI 2011
Expansion of Provider Initiated Testing
(PIHCT)--Ethiopia
250,000
80 health facilities
HIV Counseled 2,077,592
HIV Tested 1,762,636
HIV +ve: 44,835 (2.5%)
Number of patients
200,000
150,000
Counseled
100,000
Tested
Tested HIV positive
50,000
Enrolled
0
Quarter
ICAP-supported sites--Ethiopia
HIV Concordance/Discordance in
Couples (DHS)
Eyawo et al. Lancet 2010
Couples Versus Individual Counseling and
Testing-- Tanzania
• 1521 women attending three ANC randomized
to Couples C&T versus Individual C&T
Variable
Couple C&T
Individual C&T
Proportion women receiving result
39%
71%
HIV positive women
Receive ARV for PMTCT
Infants receive ARV for PMTCT
90%
55%
60%
22%
Becker et al, AIDS Beh 2010
CUMULATIVE ENROLLMENT IN HIV CARE
AND TREATMENT
1,200,000
900
768
clinics
800
1,000,000
700
1,113,543
in care
600,000
561,722 on ART
400,000
500
400
300
200
200,000
0
600
100
Mar-05
Mar-06
HIV Care
Mar-07
ART
Mar-08
Mar-09
Mar-10
0
Mar-11
Care and treatment clinics currently reporting
ICAP-Supported Programs
Number of clinics
Number of patients
800,000
Family Enrollment Form
Date: ____/____/____
ART Client - Unique ART No. of the Index Client: __________________________________
Pre ART Client - Pre ART Serial No (Facility card number): ___________________________
Family Code Number: _________________________________________________________
Woman (Mother), Age:
______
Man (Father), Age:
_______
0
1
2
3
4
5
_____6______
0
3
_
UAN:
UAN:
1st child, Age: _______
2nd child, Age: ______
3rd child, Age: ______
4th child, Age: ______
0
3
6
0
3
_6
0
3
6__
0
3
6_
1
4
7__
2
5
1
5
2
4
7_ _
UAN:
UAN:
1
2
4
5
6______
1
4
2
5
7_____
UAN:
UAN:
5th child, Age: ______
6th child, Age: ______
7th child, Age: ______
0
3
6
0
3
6
0
3
6_
UAN:
1
2
4
5
_7______
UAN:
0 = Not counseled
1 = Counseled not Tested
2 = HIV-exposed infant
3 = HIV Negative
1
2
4
5
7______
1
2
4
5
7_____
UAN:
4 = HIV Positive
5 = Pre-ART
6 = ART
7 = Died
1
2
4
5
7______
HIV Care Continuum
ART eligible
HIV
Diagnosis
Pre-ART
Monitoring and Retention
in Care
ART
Monitoring, Retention and
Adherence Support
From HIV Testing to HIV Care to ART Initiation-Mozambique
23,430 Tested for HIV
7,005 Tested HIV positive (30%)
3,049 (43%) not enrolled in
HIV care
3,956 Enrolled HIV care < 30 days after HIV test (57%)
910 (23%) No CD4 test drawn
3,046 CD4 test <30 days after enrollment (77%)
1,506 Eligible for ART Initiation (49%)
1,035 (69%) did not initiate ART
471 Initiated ART < 90 days after CD4 test (31%)
65 (14%) LTFU after ART
317 Adherent to ART for 6 months (83%)
Micek et al JAIDS 2009
HIV Care Cascade
by Testing Site
• 62.6% newly
diagnosed patients
linked to care
• Highest % linkage
in STI tested
(84.1%)
• Lowest % linkage
in VCT (53.5%)
Kranzer Plos Med 2010
Eggers et al, CROI 2007
Median CD4 Count at Enrollment into Care,
by Point of Referral
Median CD4 count (cells/uL) at
enrollment into care
700
600
500
400
300
200
100
0
Point of referral into HIV care
ICAP-Supported Programs
Median CD4 count at enrollment into care,
by enrollment year
Median CD4 count (Cells/uL) at enrollment into care
600
500
400
306 cells/uL
Overall
300
Kenya
242 cells/ul
Mozambique
Rwanda
200
Tanzania
100
0
2005
2006
2007
2008
2009
2010
2011
Year of enrollment into care
ICAP-Supported Programs
HIV Care Continuum
ART eligible
HIV
Diagnosis
Pre-ART
Monitoring and Retention
in Care
ART
Monitoring, Retention and
Adherence Support
Retention in ART Programs
Meta-analysis SSA
36 cohorts
226,307 patients
All losses except transfers
Retention:
•6 months: 86.1%
•12 months: 80.2%
•24 months: 76.8%
•36 months: 72.3%
Fox and Rosen, Trop Med Int Health 2010
Interventions
Intervention
Outcome
POC CD4 at HIV Test
Linkage to care
ART initiation
Case Manager
Linkage to care
Adherence support activities
(counseling, home visits, treatment
preparation, supportive supervision by RN
Retention and ART adherence
Cash transfer (transport)
Retention
Free cotrimoxazole
Retention of pre-ART patients
Food package
Visit adherence
Peer educators
Retention (not adherence)
SMS messaging
Adherence
Faal et al IAS 2010
Jani et al IAS 2010
Gardner et al JAMA 2005
Etienne et al. Trop Med Int Health 2010
Emenyonu CROI 2010
Kohler et al CROI 2011
Ivers et al. AIDS Res Therapy 2010
Chang et al, Plos One June 2010
ART for Prevention:
A Multi-Component Strategy
•
•
•
•
•
Expanded testing
Linkage to care
Initiation of ART
Adherence support
Positive prevention
Plus
• Community Mobilization
• Policies and Guidelines
• Buy-in by PLWH
Positive
Prevention
Testing
Antiretroviral
Treatment
Linkage
Adherence
Time for Action
PIVOTAL STUDY FINDS THAT HIV MEDICATIONS ARE HIGHLY EFFECTIVE AS
PROPHYLAXIS AGAINST HIV INFECTION IN MEN AND WOMEN IN AFRICA
HIV Prevention Trial (HPTN 052) Releases New Findings
Early initiation of ART leads to 96% reduction in HIV transmission
according to study conducted by HIV Prevention Trials Network
ART for Prevention
•
•
•
•
•
Annual testing by all >15 year old individuals
All HIV+ individuals started on ART immediately
99% decrease in infectiousness
High adherence with ART
Low failure with first line ART
•
95% reduction in new HIV cases in
10 years
•
HIV Incidence reduced from
15-20,000 to 1000 per million
Prevalence decreases to less than
1% by 2050
•
Granich et al Lancet 2009; 373:48-57
Granich et al, Lancet 2009
Populations Demographics and
Couple Serostatus
El-Sadr, Coburn, Blower
Change in HIV Incidence with Increasing ART
Coverage in Discordant Couples
Treatment Coverage and Infections
Prevented
El-Sadr, Coburn, Blower
Conclusions-1
• Evidence accumulating on the value of ART for
prevention of HIV transmission
• Several challenges and opportunities impede/enable the
potential of ART for prevention (and for treatment)
– Expansion of HIV testing
– Identification of individuals earlier in HIV disease
– Optimization of HIV care cascade
(from testing to linkage to ART initiation to retention and adherence)
Seek, Link, Treat, Retain and Support
Conclusions-2
• Implementation and scale-up need to be guided by
evidence, prioritization, adaptation, innovation,
monitoring and evaluation
• Need for continued research to:
– Determine the feasibility and effectiveness of ART as prevention at a
population level
– Examine the effect(s) of combined interventions
– Identify interventions to enable/maximizing every step of the HIV care
cascade
– Conduct modeling to guide prioritization and action at country levels
Thank you