test and treat: the gardner cascade in context
DESCRIPTION
Nicole Johns (OHP)'s presentation to the RWPC's Comprehensive Planning Committee on the implications of the Gardner Cascade for the Philadelphia EMA.TRANSCRIPT
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)
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
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
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
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
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
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.
Model Demonstrating the Spectrum of Engagement in HIV Care in the United States
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