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IAS–USA

Treatment as Prevention:Evaluating the Impact of HAART Expansion

The British Columbia (BC) Experience

AU EDITED FINAL: 03-18-13

Julio Montaner, MDProfessor of Medicine, and Head, Div. of AIDS, University of British Columbia

Director, BC-Centre for Excellence in HIV/AIDS at Providence Health CarePast President, International AIDS Society (2008-2010)

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January 2004

Summer of 1996

Year

Summer of 2000

Phase I Phase II Phase III

Montaner et al, Lancet, 2010

Increasing HAART Coverage within Evolving Guidelines in BC

N = 7492 by the end of 2011

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BC: All Cause Mortality (#)

0

50

100

150

200

250

300

350

400

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Years

Freq

uenc

y

> 90% Decrease in All Cause Mortality among HIV Infected Individuals in BC since 1996

Montaner et al, TasP Workshop, April 2012

Slide 4 of 44AIDS New Cases for BC by year, 1996-2011

Lima et al, in preparation, 2013

Slide 5 of 44HAART Use & New HIV Diagnoses for BC by year, 1996-2012

Lima et al, in preparation, 2013

HIV Incidence

Active on HAART

New HIV Diagnoses (All)

New HIV Diagnoses (Ever IDU)

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Slide 10 of 44Engagement in the Cascade of Care in BCNosyk et al, in preparation, 2012

Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009

Supp rate: 35% [30% - 40%] for pVL ≤40c/mL x2. Supp rate: 51 & 60% for a single pVL<50 or <500c/mL, respectively.

Engagement in the Cascade of Care in BCNosyk et al, TasP Workshop, 2013Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009

We used pVL ≤40c/mL x2, thus overall supp rate is: 35% [30% - 40%].

This becomes 51% & 60% if a single pVL<50 or <500c/mL are used.

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Cascade of Care by HA

Lima V, Lourenco L, et al, in preparation, 2013

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Cascade of Care by Gender

Lima et al, in preparation, 2013

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Cascade of Care by Age

Lima et al, in preparation, 2013

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Programmatic Compliance Score Assesses the impact of non-

compliance with HIV treatment guidelines on all-cause mortality

PCS components include: Baseline CD4 > 200/mm3 Three CD4 in 1st year Three VL in 1st year Baseline resistance Recommended HAART Undetectable pVL at 9 months

Failure to meet a given component add one to the score

PCS predicts mortality

Lima et al. PLoS ONE 7(11): e47859. 2012

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PCS in BC 2000 to 2011

Lima et al, in preparation, 2013

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TasP Monitoring in the Real World

• In a perfect world, all HIV infected individuals would follow the same pathway in the spectrum of engagement into care:

• In the real world, there is attrition between each of these steps and individuals are often lost-to-follow-up.

• Understanding the attrition points (leakage), and their causes are essential to optimize the effectiveness of TasP.

• This can only be achieved by comprehensively monitoring standardized metrics, on a longitudinal basis and accounting for multiple sources of bias and heterogeneity (i.e.: geographic, socio-demographic, risk factors, etc).

HIV

InfectedHIV

Diagnosed

Linked to HIV Care

Retained in HIV

Care

Need ART

On ART

Adherent/Suppressed

Link4th Intl HIV TREATMANT AS PREVENTION Workshop

April 1st to 4th 2014 - Vancouver, BC, Canada.

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In Collaboration with PHC, VCHA, NHA, PHSA, Community, and MoH