Slide 1 of 42

IAS–USA

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

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

Treatment as Prevention The Key to an AIDS & HIV free Generation

or Harnessing the Full Power of

Administrative and Clinical Data

AU EDITED FINAL: 03-18-13

Slide 2 of 44

0

5

10

15

20

25

30

35

40

82 84 86 88 90 92 94

Year

Dea

ths

per 1

00,0

00 P

opul

atio

n

Unintentional injury Cancer

Heart disease Suicide

HIV infection

Homicide

Chronic liver disease Stroke

Diabetes

USA - Trends in Annual Rates of Death Ages 25 to 44

Vancouver 1996 “One World One Hope”

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

New HIV and Syphilis in BC

BC-CDC, 2005

HAART stops HIV replication

↓

HIV load falls to undetectable levels in plasma

as well as in sexual fluids ↓

Sharp reduction in HIV transmission

Cost of Medical Management of 1 HIV infection over a lifetime = $250,000

“HIV deficit” in BC in 2005: 400

TasP is Cost-Averting

Averted lifetime Rx cost up to 2001 US $96.4M A total of 3,963 pts were on HAART in BC in 2005

Total actual drug cost (using patented drugs) in 2005 $49 million US

800 cases per year

400 cases per year

If the cost of Medical Management of 1 HIV infection over a lifetime is about $250,000

Averted lifetime Rx cost up to U$A 100M A total of 3,963 pts were on HAART in BC in 2005

Total actual drug cost (using patented drugs) in 2005

U$A 50M

“HIV deficit” in BC in 2005: 400

TasP is Cost-Averting

Incremental net benefit (Millions of CDN $) over

30 years

K Johnston et al, AIDS, 2010

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

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

Frequency

Montaner et al, TasP Workshop, April 2012

Slide 13 of 44 AIDS New Cases for BC by year, 1996-2011

Montaner et al, Under Review, 2013

1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$AIDS$0$BCCDC$Rate$ 6.9$ 4.3$ 4.4$ 4.2$ 4.3$ 2.5$ 3.2$ 3.3$ 3.1$ 3.1$ 2.8$ 2.6$ 2.7$ 2.1$ 1.6$ 1.4$

AIDS$and$CD4$Rate$ 15.6$ 9.8$ 8.9$ 8.6$ 8.1$ 6.9$ 7.8$ 8.4$ 7.7$ 8.3$ 7.6$ 7.6$ 7.1$ 5.5$ 4.5$ 3.8$

AIDS$0$BCCDC$Cases$ 269$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ 110$ 118$ 93$ 72$ 64$

AIDS$and$CD4$Cases$ 604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$

HIV0related$Mortality$Rate$ 6.5$ 3.0$ 2.8$ 2.6$ 3.0$ 2.7$ 2.6$ 3.1$ 2.5$ 3.5$ 3.3$ 2.3$ 1.8$ 1.4$ 1.2$ 1.3$

HIV0Related$Mortality$Cases$ 253$ 117$ 110$ 103$ 122$ 111$ 106$ 127$ 105$ 146$ 142$ 100$ 79$ 63$ 54$ 59$

0$

2$

4$

6$

8$

10$

12$

14$

16$

Rate%per%100,000%pop

ula.

on%

1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$AIDS$0$BCCDC$Rate$ 6.9$ 4.3$ 4.4$ 4.2$ 4.3$ 2.5$ 3.2$ 3.3$ 3.1$ 3.1$ 2.8$ 2.6$ 2.7$ 2.1$ 1.6$ 1.4$

AIDS$and$CD4$Rate$ 15.6$ 9.8$ 8.9$ 8.6$ 8.1$ 6.9$ 7.8$ 8.4$ 7.7$ 8.3$ 7.6$ 7.6$ 7.1$ 5.5$ 4.5$ 3.8$

AIDS$0$BCCDC$Cases$ 269$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ 110$ 118$ 93$ 72$ 64$

AIDS$and$CD4$Cases$ 604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$

HIV0related$Mortality$Rate$ 6.5$ 3.0$ 2.8$ 2.6$ 3.0$ 2.7$ 2.6$ 3.1$ 2.5$ 3.5$ 3.3$ 2.3$ 1.8$ 1.4$ 1.2$ 1.3$

HIV0Related$Mortality$Cases$ 253$ 117$ 110$ 103$ 122$ 111$ 106$ 127$ 105$ 146$ 142$ 100$ 79$ 63$ 54$ 59$

0$

2$

4$

6$

8$

10$

12$

14$

16$Ra

te%per%100,000%pop

ula.

on%

BC: HIV Prevalence and TB Incidence

 James  Johnston,  in  prepara/on,  May  2013  

Slide 15 of 44

HAART Use & New HIV Diagnoses for BC by year, 1996-2012

1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$HIV$Incidence$ 632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$New$HIV$Diagnoses$ 702$ 519$ 471$ 416$ 400$ 420$ 418$ 408$ 442$ 400$ 361$ 391$ 345$ 337$ 301$ 289$ 238$New$HIV$Diagnoses$(ever$IDU)$ 352$ 215$ 177$ 159$ 152$ 132$ 156$ 136$ 137$ 125$ 115$ 118$ 65$ 64$ 52$ 34$ 29$AcAve$on$HAART$ 837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$HIV$Prevalence$ 7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$

0$

1000$

2000$

3000$

4000$

5000$

6000$

7000$

0$

100$

200$

300$

400$

500$

600$

700$

800$

Number$o

s$individuals$on$HAART$

Number$of$new$cases$and$new$diagnoses$

HIV Incidence

Active on HAART

New HIV Diagnoses (All)

New HIV Diagnoses (Ever IDU)

HAART Use & New HIV Diagnoses for BC by year, 1996-2012

1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$HIV$Incidence$ 632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$New$HIV$Diagnoses$ 702$ 519$ 471$ 416$ 400$ 420$ 418$ 408$ 442$ 400$ 361$ 391$ 345$ 337$ 301$ 289$ 238$New$HIV$Diagnoses$(ever$IDU)$ 352$ 215$ 177$ 159$ 152$ 132$ 156$ 136$ 137$ 125$ 115$ 118$ 65$ 64$ 52$ 34$ 29$AcAve$on$HAART$ 837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$HIV$Prevalence$ 7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$

0$

1000$

2000$

3000$

4000$

5000$

6000$

7000$

0$

100$

200$

300$

400$

500$

600$

700$

800$Number$os$individuals$on$HAART$

Number$of$new$cases$and$new$diagnoses$

HIV Incidence

Active on HAART

New HIV Diagnoses (All)

New HIV Diagnoses (Ever IDU)

Updated  from  Montaner  et  al,  Lancet,  2010  

HAART  use  and  HIV  new  Diagnoses  Bri/sh  Columbia,  1996  -­‐  2012  

Slide 16 of 44

1 1HIV+  Birth  

Slide 17 of 44

5

0

10

15

20

1995 1998 2001 2004 2007 2010

B.C.

Ontario

QuébecAlberta

Manitoba

Manitoba

Sask.

Sask.

Atlantic

B.C.Ontario

QuébecAlberta

Atlantic

HIV

Dia

gnos

es

per

100,

000

Pop

ulat

ion

Year

HIV Diagnoses by Region and Year!Public Health Agency of Canada!

Hogg et al, HIV Medicine, 14, 581-2, 2013

Slide 18 of 44 When to start: Potential scenarios

   

Recommended Since 2002

CD4  ≤  200  

     

CD4  ≤  350  +  

     

CD4  ≤  350  +    

Expanded  CD4  independent  condi6ons  

Test and treat

All  HIV+  

Estimated millions of people eligible for ART in lower & middle-income countries in 2011

11 15 23 >25 32

1 2 3 5

International AIDS Society Conference, KL, July 2013

           

CD4  ≤  500  

4

 ART  regardless  of  CD4s:  -­‐  HIV-­‐SD    couples  •  TB/HIV    •  HBV/HIV  •  Pregnant  women  •  Children  ≤  5yo  

 

Slide 19 of 44

Status Quo 2011

Enhanced Investment 2012

2013 WHO Guidelines

2013 WHO Guidelines plus Optimized PrEP and HIV Vaccine

 Manuscript  under  preparaGon  

Slide 20 of 44

Granich et al

Lives Saved (x 1,000) U$A Billions

Slide 21 of 44

Treatment 2.0:

A new prevention-treatment

paradigm in the global response

to HIV/AIDS -

UNGASS

New York - 9 June 2010

Slide 22 of 44

Feb 2011: China Embraces TasP February 24th 2011

Slide 23 of 44

Oct 3rd 2013

Oct 17th 2013 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.

Slide 24 of 44

"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

Slide 25 of 44

Premier  Christy  Clark  announces  AIDS  2015  -­‐  The  8TH  IAS  Conference  on  HIV  Pathogenesis,  Treatment  and  Preven/on,  Vancouver,  July  2015    

   

July  3rd  2013  |  Kuala  Lumpur,  Malaysia