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Treatment as Prevention: The Key to an AIDS-Free Generation. Julio S. G. Montaner, MD Professor of Medicine University of British Columbia. From JS Montaner , MD, at San Francisco, CA: March 29, 2013, IAS-USA. . Death Rate per 1000. Life Expectancy at age 20. 140. 35. 120. 30. 100. 25. - PowerPoint PPT Presentation
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Slide 1 of 42
IAS–USA
Julio S. G. Montaner, MDProfessor of Medicine
University of British Columbia
Treatment as Prevention:The Key to an AIDS-Free Generation
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 2 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Impact of HAART in BC-CfE
0
20
40
60
80
100
120
140
1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
Death Rate per 1000
0
5
10
15
20
25
30
35
1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
Life Expectancy at age 20
Modified from Hogg et al, Lancet. 2009
Slide 3 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
New HIV and Syphilis in BC
BC-CDC, 2005
Slide 4 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 4 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 5 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HAART stops HIV replication
HIV load falls to undetectable levels in plasma
as well as in sexual fluids
Sharp reduction in HIV transmission
Slide 5 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 6 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Wood et al, BMJ, 2009
Whiskers represent 95% confidence intervals.
Slide 6 of 20
Slide 7 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HAART Reduces HIV incidence in IDUs
• From 1997, HIV incidence decreased by 74%
for each log decline in community HIV viral load
• In a separate model, HIV incidence decreased
by 5% for each 1% increase in HAART coverage
Modified from G Kirk et al, for the Alive Cohort, CROI 2011
Slide 8 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
HR = 96.3% reduction in transmission
No difference whether index pt was M or F
Deferred
Immediate
%
HPTN 052: Immediate vs Delayed ART in Sero-discordant Couples
Cohen MS, et al. IAS 2011. Abst MOAX0102 Cohen MS, et al. N Engl J Med. 2011
Slide 9 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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
Slide 9 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 10 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
BC: AIDS Cases Diagnosed (Rate per 100K)
> 80% Decrease in AIDS case report rate in BC since the pre cART era
Slide 11 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
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 12 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA. Updated from Montaner et al, Lancet, 2010, presented at TasP-Workshop, Vancouver 2012
Increasing HAART Coverage within Evolving Guidelines in BC - Impact on New Diagnoses
Slide 12 of 20
Slide 13 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Hepatitis C, 1999-2008 Infectious Syphilis, 1999-2008
Genital Chlamydia, 1999-2008 Gonorrhea, 1999-2008
• BC
x Canada
• BC
x Canada
• BC
x Canada• BC
x Canada
2004
2004 2004
2004
Slide 13 of 20
Slide 14 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 14 of 20
Slide 15 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Routine HIV testing - Acute Care
Preliminary Results, Courtesy of Scott Harrison et al
Site1
Number of
Admissions
Number Offered
Number Tested
Acceptance Rate2 % Offered % Tested
Number of Positives
Positivity Rate per 1000
SPH 3610 1626 1370 97% 45% 38% 11 ~ 8/1000
MSJ 1556 994 740 85% 64% 48% 3 ~ 4/1000
VGH 2087 1512 1196 96% 34% 27% 4 ~ 3/1000
Total 9653 4132 3306 94% 43% 34% 18 ~ 5/1000
Department of Medicine Chart Audit Data: October 2011 –December 2, 2012
1 Departments of Medicine only at each hospital site2 Acceptance rate excludes all “Not Accepted” (i.e. recent test, known HIV positive) except Pt Refusal
Slide 16 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 17 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 17 of 20
Slide 18 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Spectrum of Engagement in Care - USA
Gardner et al. CID, 2011
19% are estimated to be undetectable as a result of
HAART use*
* More recently CDC-USA revised the estimate to 28%
Slide 19 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
The Cascade of Care - 1996-2010
*
Diagnosed Linked Retained Need_ARV on ARV AdherentSuppressed
0%
10%
20%
30%
40%
50%
60%
70%
80%
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Nosyk et al, CROI, 2013
Slide 20 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Granich et al
Lives Saved (x 1,000) U$A Billions
