PWP Recommendations: Treatment As Prevention


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PWP Recommendations: Treatment As Prevention

  1. 1. PWP Recommendations: Treatment As Prevention John T. Brooks, MD 2011 National HIV Prevention Conference August 14-17, 2011 – Atlanta, GANational Center for HIV/AIDS, Viral Hepatitis, STD & TB PreventionDivision of HIV/AIDS Prevention
  2. 2. OutlineMethodsReview dataReview US existing recommendationsProposed PwP recommendation
  3. 3. MethodsRecommendations based on: Epidemiologic data • Reduction in HIV transmission risk associated with ART1 HIV treatment recommendations • U.S. Department of Health and Human Services (2009) • International AIDS Society–USA Panel (IAS-USA – 2010) Consultation and narrative review for other aspects
  4. 4. Data Review: History of ResearchObservational cohort data Suggested association low viral load (cause) reduce risk (effect)Modeling studies Suggested intervention (treating HIV infection) could reduce epidemicEcological analyses (community-based observations) Treating a population associated with reduction in new infectionsBiomedical research Established mechanism and biological plausibility of interventionRandomized clinical trial Demonstrated intervention was effective
  5. 5. Low plasma viral load in sexual partner associatedwith significantly decrease risk of HIV transmissionQuinn et al. NEJM 2000, 342:921
  6. 6. Meta-analysis indicated ART’s reduces sexual transmission of HIV in serodiscordant couples 11 cohort studies 92% reduction in HIV transmission risk: from 5.64 to 0.46 events/100 pyAttia et al. AIDS 2009, 23(11): 1397-1404
  7. 7. Mathematical modeling suggested universal “test and treat” strategy could control the epidemic Incidence 1980 2000 2020 2040 Prevalence 1980 2000 2020 2040Granich et al. Lancet 2009, 373:48-57
  8. 8. Decreasing “community viral load” and HIV diagnoses in San FranciscoDas et al. PLoS ONE 2010, 6(5):e11068
  9. 9. Decreasing “community viral load” and HIV diagnoses in British Columbia… Period of “HAART expansion” Maybe folks in BC are simply reducing number of partners and using condoms more consistently and correctly?Montaner et al. Lancet 2010, 376:532--539
  10. 10. …despite increasing rates of syphilis and gonorrheaInfectious Syphilis, 1999-2008 Gonorrhea, 1999-2008 x Canada • BC x Canada • BC Modified from
  11. 11. Viral load in plasma and genital secretions correlated, and each are correlated with risk of transmission 2,521 serodiscordant African couples : 73 men seroconverted in 1,805 couples Women Women CVL plasma : 40 women seroconverted in 716 couples Men Men semen plasmaBaeten et al., Sci Trans Med 2011, 3(77): 1
  12. 12. HPTN 052:Prevention of HIV-1 Infection with Early Antiretroviral Therapy 1,763 heterosexual couples HIV discordant CD4 count 350-500 cells/mm3 886 couples: “early therapy” 887 couples: “delayed therapy” Infected partner initiates at: Infected partner initiates at: CD4 count 350-500 cells/mm3 CD4 count < 250 cells/mm3 or AIDS-related illness Primary Outcomes: • HIV incidence in HIV-uninfected partners • HIV-associated clinical events Cohen et al., N Engl J Med 2011, 365: 493-505
  13. 13. HPTN 052:Prevention of HIV-1 Infection with Early Antiretroviral Therapy“The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1and clinical events, indicating both personal and public health benefits from such therapy” Early: 1 Early: 40 Delayed: 27 Delayed: 65 96% reduction 41% reduction Cohen et al., N Engl J Med 2011, 365: 493-505
  14. 14. Existing US RecommendationsDHHS (last updated January 2011): CD4 350-500 cells/mm3 – Recommend use CD4 >500 cells/mm3 – Optional use, not contraindicated ART for prevention – “Use of effective ART regardless of CD4 count is likely to reduce transmission to the uninfected sexual partner”
  15. 15. Caveats and Considerations to PwP RecommendationsExisting data limited mostly to heterosexualsFeasibility: limited capacity and financingEthics of individual vs. population health:→ Treating the patient for her/his own health must always be the first priority
  16. 16. RecommendationsClinical care and community settings: HIV-infected persons should be made aware of individual health benefits and risks of ART, benefit of ART in reducing the risk of HIV transmission, and the need to continue other prevention measures while taking ART (see Risk Reduction section). HIV-infected persons with ongoing HIV transmission risk behavior despite risk-reduction measures should be offered ART regardless of CD4 lymphocyte count for the potential reduction in HIV transmission risk as well as potential individual health benefit. (HIV transmission risk behavior is defined in the Risk Screening section.) HIV-infected persons initiating or continuing ART should be made aware of the need to continue other prevention measures while on ART (see Risk Reduction section) and the importance of adherence (see Adherence section).
  17. 17. RecommendationsClinical care settings: ART should be initiated for those individuals willing and able to commit to long-term ART. ART regimen selection should be guided by current ART recommendations for the optimal health of the HIV-infected individual and with greatest success of suppressing plasma viremia.
  18. 18. John T.