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Julio Montaner MD, DSc(hon), FRCPC, FCCP, FRSC, OBC Director, BC-Centre for Excellence in HIV/AIDS, Providence Health Care
Professor of Medicine and Head, Division of AIDS, University of British Columbia
Past-President, International AIDS Society
STOP HIV & AIDS Provincial Expansion Exchange Kick off
Century Plaza Hotel, Vancouver, BC, January 31st 2013
TREATMENT AS PREVENTION: MAXIMIZING THE INDIVIDUAL AND SOCIETAL
IMPACT OF HAART
HAART stops HIV replication
HIV load falls to undetectable levels in plasma
as well as in sexual fluids
Sharp reduction in HIV transmission
0
1
2
3
4
5
6
7
8
9
10
2006 2010 2014 2018 2022 2026 2030 2034 2038 2042 2046 2050
Year
HIV
in
fec
tio
ns p
er 1
000
p
op
ula
tio
n
Treat all Treat 30%
HIV prevalence
Montaner et al. Lancet, 2006
0
50
100
150
200
250
2006 2010 2014 2018 2022 2026 2030 2034 2038 2042 2046 2050
Year
Infe
cti
on
s (
mil
lio
ns
)
Infections prevented
Number of
infections
prevented
Treat all
Treat 30%
0
5
10
15
20
25
30
2006 2010 2014 2018 2022 2026 2030 2034 2038 2042 2046 2050
Year
Co
st
(billi
on
s)
Treat all Treat 30%
Cost of treatment
Treat all
Treat 30%
Hypothetical Demographic Model
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
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
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
Viral Load Suppression
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 - 2003 2004 - 2006 2007 - 2008 2009 - 03/2010 04/2010 - 03/2011
Percentage of Individuals with Suppressed Viral Load <50 copies/mL
Percentage of Individuals with Suppressed Viral Load <500 copies/mL
BC: All Cause Mortality (#) All Cause Mortality in BC
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
Fre
qu
en
cy
Montaner et al, TasP Workshop, April 2012
Increasing HAART Coverage within Evolving
Guidelines in BC - Impact on New Diagnoses
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
Updated from Montaner et al, Lancet, 2010
301 289
51 48
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
Routine HIV testing - Acute Care
Preliminary Results, Courtesy of Scott Harrison et al
Site1
Number
of
Admissi
ons
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 4487 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 site
2 Acceptance rate excludes all “Not Accepted” (i.e. recent test, known HIV positive) except Pt Refusal
DHHS, 2012: When to Start ART recommended for all HIV-infected patients
strength of recommendation varies according to CD4+ cell count
CD4+ Cell Count Recommendation
< 350 cells/mm³ Start ART (AI)
350-500 cells/mm³ Start ART (AII)
> 500 cells/mm³ Start ART (BIII)
Clinical Conditions Favoring Initiation of Therapy Regardless of CD4+ Cell Count
History of AIDS-defining illness (AI)
Pregnancy (AI)
HIV-associated nephropathy (AII)
HBV co-infection (AII)
Patients at risk of transmitting HIV to sexual partners (AI, heterosexuals; AIII, others)
HCV co-infection* (BII)
Patients > 50 years of age (BIII)
DHHS Guidelines for Antiretroviral Therapy in Adults and Adolescents. March 27, 2012.
*Including those with high CD4 count and/or with cirrhosis. If CD4> 500/mm³ may elect to defer ART until after HCV therapy
• Rating of Recommendations: A = Strong; B = Moderate; C = Optional
• Rating of Evidence: I = data from RCTs; II = data from well-designed nonrandomized trials or cohort studies with long-term clinical
outcomes; III = expert opinion
WHO Guidance on couples HIV testing and counselling
Released April 18th 2012 at
http://www.who.int/hiv/pub/guidelines/9789241501972/en/index.html
Strong recommendation, high quality evidence.
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%
The Cascade of Care - 1996-2010
* 1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
Nosyk et al, in preparation, 2012
Cascade of Care by Gender
7733 7219
5231 4983 4886 4112
3547
0
2000
4000
6000
8000
10000Males, 2010
-28%
-7%
-5% -2% -16% -14%
1874 1681
1095 998 964
667 517
0
500
1000
1500
2000Females, 2010
-35%
-10%
-31% -22%
-9% -3%
Treatment 2.0:
A new
prevention-
treatment
paradigm in the
global response
to HIV/AIDS
-
UNGASS
New York - 9 June 2010
Few could have imagined that we’d be talking about the real possibility of an
AIDS-free generation. But that’s what we’re talking about…make no mistake,
we are going to win this fight.
President Obama, December 1, 2011
PS: By the end of 2013, PEPFAR will directly support more than 6 M people on HAART– 2M more
than previously targeted.
"To cut new infections in half, we'll have to heed Julio Montaner's years of pleas to implement
Treatment as Prevention and implement combination prevention programs. We can save a lot of lives
if all this is done..."
President Clinton, Washington AIDS Conference, 2012
Supported by $48M (+ARV Drugs) 4 year award from the MoH, Gov of British Columbia,
$2.5M 5 year Avant-Garde Award (No 1DP1DA026182-01) from the National Institute for
Drug Abuse (NIDA) at the NIH, $110K Knowledge Translation Award from CIHR, and grants
from Merck, Gilead, ViiV and BMS
In Collaboration with PHC, VCHA,
NHA, PHSA, Community, and MoH