TRACK C RAPPORTEURS REPORT

Prepared by

Anne Buvé Belgium Sabina Bindra-Barnes India Saidi Kapiga Tanzania Jorge Sanchèz Peru David Wilson Australia

The CAPRISA 004 trial

Trial of vaginal microbicide: 1% Tenofovir gel in HIV negative women in South Africa

Proof of concept trial, double-blind, placebo-controlled

Coital dependent insertion of gel

The CAPRISA 004 trial

Tenofovir Placebo

HIV incidence

5.6 9.1

IRR = 0.61 (0.4 – 0.94)Protective effect 39% (6 – 60)

HSV-2 incidence

9.9 20.2

IRR = 0.49 (0.3 – 0.78)Protective effect 51% (22 – 70)

The CAPRISA 004 trial

No safety issues, no resistance detected

Excited, but not ready for roll out– One trial in one population– Adherence: can we do better?

Young people

Trends in HIV and behaviors in young people 15-24 yrs (TuAC0204)

21 countries with generalised epidemics (Africa and the Caribbean)

2000 – 2008: – significant reduction of 25% in HIV

prevalence in 10 countries– correlation with behavior change in

8

Incentivising behavior change? Malawi: Zomba cash transfer program

(SUSA22)Cash transfers to schoolgirls and young women who had recently dropped out of school to stay in (or return to) school

After 1 year, among school girlsSignificantly lower prevalence of HIV and HSV-2 in the intervention group than the control group (but no baseline data)

Effect due to schooling or higher income?

Intravenous drug users RDS survey in 8 cities in Russia (2008-

2010)– HIV: 2.6 % - 64.3% (>50% in 3 cities)– HCV prevalence: 49% - 90%– Non-IDU sexual partners: 32% - 70%MOAC0202

Zanzibar (2007): first RDS survey among IDU in Africa– HIV: 16% ,associated with high risk sexual

behaviorMOAC0401

Needle and syringe programmes NSPs in Australia (MOAC0403)

– In the past 10 years, for every 1$ invested in NSPs0.2 days of disability adjusted life

saved> 4$ returned in health care cost

savings

Needle and syringe programmes NSPs in Estonia (MOAC0402)

– 2003 – 2009: numbers of needles distributed from 18,000 to >770,000

– 2005-2009: HIV incidence among new injectors (start injecting < 5 yrs ago)

18 / 100 pyrs to 7.5 / 100 pyrs

Strong evidence on cost-effectiveness but policies and laws block implementation (Lancet series).

MSM

Survey in Kampala (Uganda) – RDS– HIV: 14%– Recruitment difficult because of

police actionsOpening session:”Human rights violations are a barrier to knowing your epidemic”

(TUAC0305)

MSM

South Africa and Senegal: difficult access to prevention and care services (WEPDC101 & WEPDC102)

Lack of understanding of risk behaviors by service providers - risky behaviors with female partners.

Commercial sex workers Avahan: program targeting sex

workers in 6 states in India – worldwide largest SW program

Karnataka: baseline survey and follow-up survey– Longer duration of program exposure

associated with increased condom use– Significant reduction in HIV: 19.6% to

16.4%

Male circumcision: where are we? Kenya: rapid scale up was feasible and

safe – task shifting

Kisumu (Kenya): population based survey– Increase in prevalence of MC– No evidence of sexual risk compensation.

(THAC0103 & THAC0101)

Mother-to-child transmission Coverage of PMTCT in Eastern

and Southern Africa: 58% (THSY09)

The Antiretroviral Pregnancy Registry: – Overall prevalence of birth defects

for any ART exposure during pregnancy: 2.7 per 100 live births(session WEAX01)

Treatment as prevention Biological plausibility

Mathematical models

Empirical evidence– Individual level: discordant couples

Risk of transmission very low but not 0– Population level: ecological analyses, e.g.

British Columbia, Denmark (MOAC0103)

Treatment as prevention Issues (WESY0705)

– Transmission during acute infection: how much?

– Transmission of resistant strains– Sustainability of viral suppression:

how long?

Combination prevention “The strategic, simultaneous use of

different classes of prevention activities (biomedical, behavioral, social/ structural) that operate on multiple levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritizing, partnership and engagement of affected communities”.

Combination prevention Challenging to evaluate

– RCTs difficult, may not be suited– Use of variety of methods and data

sources– Make pathway to impact explicit