Slide 1 of 42

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

Harnessing the Full Power of
Administr...
Slide 2 of 44

USA - Trends in Annual Rates of Death
Deaths per 100,000 Population

Ages 25 to 44

40

Unintentional
injur...
Vancouver 1996
“One World One Hope”
Impact of HAART in BC-CfE
140

Death Rate per 1000

Life Expectancy at age 20

35

120

30

100

25

80

20

60

15

40

1...
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 reducti...
TasP is Cost-Averting
“HIV deficit” in BC in 2005: 400
Cost of Medical Management of 1 HIV infection over a
lifetime = $25...
TasP is Cost-Averting
“HIV deficit” in BC in 2005: 400
If the cost of Medical Management of 1 HIV infection
over a lifetim...
Incremental net
benefit (Millions
of CDN $) over
30 years

K Johnston et al,
AIDS, 2010
Increasing HAART Coverage within
Evolving Guidelines in BC
N = 7492 by the
end of 2011

January 2004
Summer of 2000
Summer...
BC: All Cause Mortality (#)
All	
  Cause	
  Mortality	
  in	
  BC
400
350
300

Frequency

250
200
150
100
50
0
1996

1997
...
Slide 13 of 44

AIDS New Cases for BC by year,
1996-2011
16$
16$

14$
Rate%per%100,000%popula.on%
Rate%per%100,000%popula....
BC: HIV Prevalence and TB Incidence

	
  James	
  Johnston,	
  in	
  prepara/on,	
  May	
  2013	
  
800$

Slide 15 of7000$
44

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

500$
500$

400$
...
Slide 16 of 44

HIV+	
  Birth
	
  
1

1
Slide 17 of 44

HIV Diagnoses by Region and Year
!
20

Public Health Agency of Canada
!

HIV Diagnoses
per 100,000 Populat...
When to start: Potential scenarios
Estimated millions of people eligible for ART
in lower & middle-income countries in 201...
Slide 19 of 44

Status Quo 2011

Enhanced Investment 2012
2013 WHO Guidelines
2013 WHO Guidelines plus Optimized PrEP and ...
Slide 20 of 44

Lives Saved (x 1,000)

Granich et al

U$A Billions
Slide 21 of 44

Treatment 2.0:
A new
preventiontreatment
paradigm in the
global response
to HIV/AIDS
UNGASS
New York - 9 J...
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...
Slide 24 of 44

"To cut new infections in half, we'll have to heed Julio Montaner's years of pleas to implement
Treatment ...
Slide 25 of 44
Premier	
  Christy	
  Clark	
  announces	
  AIDS	
  2015	
  -­‐	
  The	
  8TH	
  IAS	
  Conference	
  
on	
  HIV	
  Pathog...
Treatment as Prevention The Key to an AIDS & HIV free Generation or Harnessing the Full Power of Administrative and Clinic...
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Treatment as Prevention The Key to an AIDS & HIV free Generation or Harnessing the Full Power of Administrative and Clinical Data - Julio Montaner

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Treatment as Prevention The Key to an AIDS & HIV free Generation or Harnessing the Full Power of Administrative and Clinical Data - Julio Montaner

  1. 1. Slide 1 of 42 Treatment as Prevention The Key to an AIDS & HIV free Generation or Harnessing the Full Power of Administrative and Clinical Data 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) AU EDITED FINAL: 03-18-13 IAS–USA
  2. 2. Slide 2 of 44 USA - Trends in Annual Rates of Death Deaths per 100,000 Population Ages 25 to 44 40 Unintentional injury Cancer 35 30 Heart disease Suicide 25 20 15 HIV infection 10 Homicide 5 0 82 84 86 88 Year 90 92 94 Chronic liver disease Stroke Diabetes
  3. 3. Vancouver 1996 “One World One Hope”
  4. 4. Impact of HAART in BC-CfE 140 Death Rate per 1000 Life Expectancy at age 20 35 120 30 100 25 80 20 60 15 40 10 20 5 0 0 1993-94 1995-96 1997-98 1999-00 2001-02 2003-04 1993-94 1995-96 1997-98 1999-00 2001-02 2003-04 Modified from Hogg et al, Lancet. 2009
  5. 5. New HIV and Syphilis in BC BC-CDC, 2005
  6. 6. HAART stops HIV replication ↓ HIV load falls to undetectable levels in plasma as well as in sexual fluids ↓ Sharp reduction in HIV transmission
  7. 7. TasP is Cost-Averting “HIV deficit” in BC in 2005: 400 Cost of Medical Management of 1 HIV infection over a lifetime = $250,000 800 cases per year Averted lifetime Rx cost up to 2001 US $96.4M A total of 3,963 pts were on HAART in BC in 2005 400 cases per year Total actual drug cost (using patented drugs) in 2005 $49 million US
  8. 8. TasP is Cost-Averting “HIV deficit” in BC in 2005: 400 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
  9. 9. Incremental net benefit (Millions of CDN $) over 30 years K Johnston et al, AIDS, 2010
  10. 10. Increasing HAART Coverage within Evolving Guidelines in BC N = 7492 by the end of 2011 January 2004 Summer of 2000 Summer of 1996 Phase I Phase II Year Phase III Montaner et al, Lancet, 2010
  11. 11. BC: All Cause Mortality (#) All  Cause  Mortality  in  BC 400 350 300 Frequency 250 200 150 100 50 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Years Montaner et al, TasP Workshop, April 2012
  12. 12. Slide 13 of 44 AIDS New Cases for BC by year, 1996-2011 16$ 16$ 14$ Rate%per%100,000%popula.on% Rate%per%100,000%popula.on% 14$ 12$ 12$ 10$ 10$ 8$ 8$ 6$ 6$ 4$ 4$ 2$ 2$ 0$ AIDS$0$BCCDC$Rate$ 0$ 1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 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$ 1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ AIDS$and$CD4$Rate$ AIDS$0$BCCDC$Rate$ 15.6$ 9.8$ 6.9$ 4.3$ AIDS$0$BCCDC$Cases$ AIDS$and$CD4$Rate$ 269$ 9.8$ 8.9$ 8.6$ 8.1$ 6.9$ 7.8$ Montaner et 7.6$ 110$ 118$ 5.5$ 4.5$ 3.8$ 15.6$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ Under Review, 2013 8.4$ 7.7$ 8.3$ al, 7.6$ 7.1$ 93$ 72$ 64$ AIDS$and$CD4$Cases$ AIDS$0$BCCDC$Cases$ HIV0related$Mortality$Rate$ AIDS$and$CD4$Cases$ 8.9$ 4.4$ 8.6$ 4.2$ 8.1$ 4.3$ 6.9$ 2.5$ 7.8$ 3.2$ 8.4$ 3.3$ 7.7$ 3.1$ 8.3$ 3.1$ 7.6$ 2.8$ 7.6$ 2.6$ 7.1$ 2.7$ 5.5$ 2.1$ 4.5$ 1.6$ 3.8$ 1.4$ 604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$ 269$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ 110$ 118$ 93$ 72$ 64$ 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$ 604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$
  13. 13. BC: HIV Prevalence and TB Incidence  James  Johnston,  in  prepara/on,  May  2013  
  14. 14. 800$ Slide 15 of7000$ 44 Number$of$new$cases$and$new$diagnoses$ Number$of$new$cases$and$new$diagnoses$ 500$ 500$ 400$ 400$ 300$ 300$ HIV Incidence New HIV Diagnoses (All) New HIV Diagnoses (All) 200$ 200$ 100$ 4000$ 4000$ 3000$ 3000$ 2000$ 1000$ 100$ 0$ HIV$Incidence$ HIV Incidence Number$os$individuals$on$HAART$ Number$os$individuals$on$HAART$ HAART Use and  HIV  new  Diagnoses   HAART  use   & New HIV Diagnoses7000$ 800$ 700$ Bri/sh   by year, 1996-2012HAART 012   on Active for BC Columbia,  1996  -­‐  2Diagnoses6000$ HAART Use & New HIV 700$ 6000$ 600$ 5000$ for BC by year, 1996-2012 600$ 5000$ Active on HAART New HIV Diagnoses (Ever IDU) New HIV Diagnoses (Ever IDU) 1000$ 0$ 1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$ 0$ 0$ 1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$ 632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$ HIV$Incidence$ New$HIV$Diagnoses$ 632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$ 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$ 345$ 337$ 301$ 289$ 238$ New$HIV$Diagnoses$ 702$ 519$ 471$ 416$ 400$ 420$ 418$ 408$ 442$ 400$ 361$ 391$ 65$ 64$ 52$ 34$ 29$ AcAve$on$HAART$ New$HIV$Diagnoses$(ever$IDU)$ 837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$ 352$ 215$ 177$ 159$ 152$ 132$ 156$ 136$ 137$ 125$ 115$ 118$ 65$ 64$ 52$ 34$ 29$ HIV$Prevalence$ AcAve$on$HAART$ 7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$ HIV$Prevalence$ 7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$ 837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$ Updated  from  Montaner  et  al,  Lancet,  2010  
  15. 15. Slide 16 of 44 HIV+  Birth   1 1
  16. 16. Slide 17 of 44 HIV Diagnoses by Region and Year ! 20 Public Health Agency of Canada ! HIV Diagnoses per 100,000 Population B.C. Sask. 15 Ontario 10 5 0 Manitoba Ontario B.C. Québec Alberta Québec Alberta Manitoba Sask. Atlantic 1995 Atlantic 1998 2001 2004 2007 2010 Hogg et al, HIV Medicine, 14, 581-2, 2013 Year
  17. 17. When to start: Potential scenarios Estimated millions of people eligible for ART in lower & middle-income countries in 2011 15 23 >25 11 1 CD4  ≤  200       Recommended Since 2002       2 CD4  ≤  350   +   3 4 CD4  ≤  500   CD4  ≤  350   +           Expanded  CD4     independent       condi6ons       ART  regardless  of  CD4s:     HIV-­‐SD    couples     TB/HIV     HBV/HIV   Pregnant  women   Children  ≤  5yo     Slide 18 of 44 32 5 Test and treat All  HIV+   -­‐  •  •  •  •  International AIDS Society Conference, KL, July 2013
  18. 18. 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  
  19. 19. Slide 20 of 44 Lives Saved (x 1,000) Granich et al U$A Billions
  20. 20. Slide 21 of 44 Treatment 2.0: A new preventiontreatment paradigm in the global response to HIV/AIDS UNGASS New York - 9 June 2010
  21. 21. Slide 22 of 44 Feb 2011: China Embraces TasP February 24th 2011
  22. 22. 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.
  23. 23. 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
  24. 24. Slide 25 of 44
  25. 25. 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

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