Test and Treat: The Gardner Cascade in Context

TEST AND TREAT

Gardner Cascade in context

Intro to ‘Test and Treat’

Most people in HIV treatment (ART) reach undetectable VL

People with undetectable viral load are significantly less likely to transmit virus

Collectively, individuals with lower VL lead to communities with lower community VL = less transmissions

Failures in the system of care pose barriers to full success of T&T: Late diagnosis Non-linkage or flawed linkage to care Insufficient use of ART Non-adherence to ART

Test and Treat Components (HRSA)

Testing and identification of PLWHA as soon as possible

Linkage of people testing positive for HIV to HIV care

Patient education to encourage self management and facilitate retention in care, adherence to treatment, and prevention of STIs

Supportive services for promotion of sexual health maintenance

Monitoring and evaluation of test and treat strategy

Intro to Gardner’s Research

Test and treat strategy supported by mathematical models and epidemiological data

Areas with high coverage of ART have decreased incidence of HIV

HOWEVER barriers to implementation of Test and Treat strategies have not been adequately evaluated.

Objectives of Gardner’s Review

To describe and quantify the spectrum of engagement in HIV care

To understand how gaps in the continuum of care affect virological outcomes in the US

To understand how to address these gaps for Test and Treat to be successful strategy

To explore effects of interventions to improve components of engagement in care

Gardner’s Review Search Strategy

PubMed search - cross-match of HIV or AIDS with Prevalence United States Incidence United States Late diagnosis Linkage to care Retention in care Engagement in care Adherence Persistence Resistance

Bibliographies of pertinent articles were reviewed

Emphasis was based on population based studies over cohort or single institution studies

HIV Care Continuum

Adapted from

Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2

Cheever LW Clin Infect Dis 2007;44:1500-2

Not in HIV Care Engaged in HIV Care

Unaware of HIV infection

Aware of HIV infection (not in care)

Receiving some medical care but

not HIV care

Entered HIV care but lost to

follow-up

Cyclical or intermittent user

of HIV care

Fully engaged in HIV care

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Undiagnosed HIV Infection

1.1 million in the US with HIV/AIDS 21% of those not aware HIV+ (US) 35%-45% of newly diagnosed individuals

have AIDS within 1 year (US)



Linkage in Care

Longer delays in linkage with medical care are associated with greater likelihood of progression to AIDS by CD4 criteria

HIV+ people not linked to care pose a greater risk of transmission

Gardner concludes that ~75% of newly diagnosed HIV+ people successfully like to HIV care within 6-12 months, 80-90% link within 3-5 years


Retention in Care

3 population based studies in US found 45-55% of known HIV+ individuals fail to receive HIV care during any year

In some communities, one-third of HIV+ people fail to access care for 3 consecutive years

~50% of HIV+ (aware) people are not engaged in regular HIV care.

Poor engagement in care is associated with poor health outcomes, including increased mortality and increased risk of HIV transmission



Antiretroviral Therapy

Gardner estimates that 80% of in-care HIV+ individuals should be receiving ART, but 25% of those are not.

4-6% of in-care HIV+ people discontinue ART each year

70-80% adherence leads to durable viral suppression in most people

78-87% of individuals on ART had an undetectable viral load.


19%

Test and Treat Implications

Epidemiological data suggests that ART reduces risk of HIV transmission in serodiscordant heterosexual couples by 92-98%

Ecological data show that incidence of HIV transmission may be occurring in communities with high treatment coverage (San Francisco)

Simulations of the Engagement in HIV Care Spectrum to Account for Inaccuracy in our Engagement Estimates

66%

21%28%34%22%19%

0

200000

400000

600000

800000

1000000

1200000

Current Dx 90% Engage 90% Treat 90% VL<50 in 90% Dx, Engage,Tx, and

VL<50 in 90%

(a) (b) (c) (d) (e) (f)

Nu

mb

er o

f In

div

idu

als

Un-Diagnosed HIV

Not Linked to Care

Not Retained in Care

ART Not Required

ART Not Utililzed

Viremic on ART

Undetectable Viral Load

Newer Data for Discussion

Marks et al. estimated that 29 – 34% of HIV-infected individuals in the U.S. have an undetectable viral load (Clin Infect Dis 2011;53:1168–9)

Dombrowski et al. estimate that 42 – 45% in Seattle King County are undetectable (AIDS 2011;epub ahead of print)

In a cohort of newly diagnosed individuals in Denver, 28% are undetectable 12 – 18 months after diagnosis.

Limitations

Unable to assess the impact of financial barriers to HIV care in the U.S.

Overlap in the stages of engagement in HIV care

Cross-sectional depiction of a longitudinal process

The review applies to the U.S. and not to resource-poor settings

Conclusions Engagement in care is critical to the

successful management of HIV infection For the individual For the population

Deficiencies in the spectrum of engagement in care present formidable barriers to ‘test and treat’ for HIV prevention: Failure to diagnose Failure to link to care Failure to be retained in care Failure to receive and adhere to antiretroviral

therapy Research is needed on ways to improve

transitions across all steps in the engagement in care cascade

Local Context of Cascade

Undiagnosed HIV/AIDS - EMA In EMA estimated 6,800 people are

unaware of their status In Philadelphia- 25% concurrent HIV/AIDS

in 2009 (a.k.a. “late testers”) – consumer survey data supports this number Most likely to be

African American/Hispanic Male Over 40 Heterosexual or unidentified risk

HIV/AIDS- Incidence

Total: 1540 72% Male 53% 20-44 44% 45+ 59% African

American/Black 21% White 14% Hispanic 44% Heterosexual 30% MSM 16% IDU

Total: 1835 73% Male 68% 20-44 25% 45+ 59% African

American/Black 22% White 16% Hispanic 38% Heterosexual 40% MSM 11% IDU

AIDS (1/1/2008 – 12/31/2010)

HIV (1/1/2008 – 12/31/2010)

HIV/AIDS Diagnosed - Prevalence

73% Male 61% 45+ 32% MSM 30% IDU 29% Heterosexual 59% African

American/Black 24% White 13% Hispanic

68% Male 54.4 % 20-44 42.9% 45+ 37% Heterosexual 33% MSM 21% IDU 56% African

American/Black 25% White 14% Hispanic

AIDS – 15,163 HIV – 10,486

Linkage to Care

Surveillance data show that 73% of PLWHA in Philadelphia are linked to care – 11,500

2010 Unmet EMA need estimate – 6,044 Philadelphia Unmet Need – 4,388

73% of PLWHA with unmet need are male 65% are African American/Black Of those with unmet need - Medicaid (29%)

and unknown insurance status (25%)

Client Services Unit

10 weeks after initial intake – 78% in MCM

Linkage to Medical care within 10 weeks – 97% (includes people already in care at intake)

26% had no insurance at intake 44% had Medicaid

Linkage to Care - Survey

74% of respondents got into care right away

85% within a year of diagnosis Late testers slightly more likely to get

into care right away 4% got into care after they were sick

Retention

7719 Philadelphia PWHA retained in care (HRSA definition)

93% of consumer survey respondents had a regular place for HIV care

77% of respondents had 3 or more HIV care visits in 12 months

95% of respondents had any # of visits in 12 months

ART and Adherence

38% of survey respondents had CD4 over 500.

33% between 200-50011% under 20013% did not know

90% of survey respondents on ART 97% of late testers 89% of HIV+

Viral Load

6,793 PLWHA on ART in Philadelphia 5,366 have suppressed viral load (79% of

ART) 67% of survey respondents report

undetectable viral load 27% of undetectables were late testers 14% did not know viral load

-

5,000

10,000

15,000

20,000

25,000

19,691

15,753

11,500

7,719 6,793

5,366

Philadelphia Estimate for Stage of Engagement in Care

Source: AACO, Dr. Kathleen Brady

Other viewpoints

Context and Controversy

HRSA’s Pros and Cons of Test and Treat

Widespread effective ART may lower community viral load

More people will benefit from treatment

Evidence shows Test and Treat works The strategy would help mitigate

health disparities Risk reduction counseling can be

included in HIV testing Test and treat would help link and

retain people in care Test and treat would present

opportunities for prevention with patients’ partners

People would receive referrals to supportive services earlier in disease course

People could begin treatment earlier in disease course

STI screening, treatment, and sexual health education would be facilitated

Widespread testing and treatment has large financial cost implications

Many barriers to HIV testing remain Modeling studies are flawed We may not be able to treat our way

out of the epidemic Demand for treatment exceeds supply Behavioral disinhibition/risk

compensation would compromise any decrease in incidence

Current testing system makes capturing acute infections difficult

Viral suppression may not be possible for everyone

Widespread treatment is unsustainable Treatment initiation may take time.

Unknown long term toxicities Stigma and discrimination continue to

exist

Pro Con

HRSA CARE ACTION, January 2012

Supporting Research

A meta analysis examined 11 cohorts of serodiscordant heterosexual couples with the HIV+ partner on ART and a VL<400 showed NO transmissions (Attia, Egger, Muller, et al., 2009)

HPTN 052 – HIV+ men and women who were on ART had a 96% reduced risk of transmitting the virus to sexual partners

Effectiveness of Test and Treat

Dodd, Garnett & Hallet, 2010 Impact of Test and Treat depends crucially on

the epidemiological context In some situations less aggressive

interventions achieve the same results Testing every year and following up with

immediate treatment is not necessarily the most cost-efficient strategy

Test and Treat intervention that does not reach full implementation or coverage could increase long-term ART costs.

Early retention in care and VL Mugavero, Amico, Westfall et al., 2012

Higher rates of early retention in HIV care are associated with achieving viral load suppression and lower cumulative viral load burden

63% of overall sample achieved viral load suppression in less than a year after entry into care

Insured people reached suppression faster The more visits (less no shows) the more likely the

person was to have viral load suppression Each clinic “no show” conveyed a 17% increased risk of

delayed viral load suppression

VL and Risk Behaviors

Kalichman, Cherry, Amaral, et al., 2010 (MSM) Nonadherence to ART was associated with greater

number of sex partners and engaging in unprotected and protected anal intercourse (not moderated by substance use)

Belief that having an undetectable viral load leads to lower infectiousness was associated with greater numbers of partners, including nonpositive partners, and less condom use

Men who had undetectable viral load and believed having an undetectable viral load made them less infectious were significantly more likely to have had an STI recently.

Beliefs regarding viral load rather than viral load itself influence behavior

Health & Medicine

Test and Treat: The Gardner Cascade in Context