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 Outcomes among

Injection Drug Users

The Vancouver Experience

Wood et al, BMJ, 2009

Whiskers represent 95% confidence intervals.

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

TasP in Serodiscordant

Couples

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

CD4 Count before HAART

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: AIDS cases Diagnosed (Rate per 100K)

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

Cascade of Care- HIV-RNA levels

*

Nosyk et al, in preparation, 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

HIV Diagnoses by Region and Year Public Health Agency of Canada

HIV Testing

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

HIV Treatment

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.

HIV Cascade of Care

Preliminary Data

FYI, only

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 age

Cascade of Care,

IDUs by age

Cascade of Care

MSM by age

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%

Let’s talk about $$$

Granich et al

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

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