Wesat2204

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Wesat2204

  1. 1. British Columbia Centre for Excellence in HIV/AIDS NIDA Satellite at the 2008 International AIDS Conference Julio Montaner MD, FRCPC, FCCP Director, BC-Centre for Excellence on HIV/AIDS Professor of Medicine and Chair, AIDS Research Providence Health Care - University of British Columbia President-Elect, International AIDS Society Expanding HAART to Curb the Spread of HIV/AIDS QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  2. 2. Prevention Strategies - Education - Change in behavior - Harm reduction - New strategies/technology - Vaccines
  3. 3. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  4. 4. Effect of HAART on HIV Transmission • MTCT • Discordant Couples • Ecological Evidence
  5. 5. The Impact of HAART on MTCT USA, 1985 - 2000 Canada, 1990 - 2004
  6. 6. Castilla, et al. JAIDS 2005; 40:96-101 Effect of HAART on Heterosexual Transmission of HIV - Spain 8.6% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 No Therapy Mono or BI Therapy HAART P = 0.0129 HAART vs other options
  7. 7. Decreased HIV Transmission after a Policy of Providing Free Access to Highly Active Antiretroviral Therapy in Taiwan JID 2004:190 (1 September), 879. Chi-Tai Fang,1 Hsu-Mei Hsu,2 Shiing-Jer Twu,2 Mao-Yen Chen,1 Yu-Yin Chang,3 Jing-Shiang Hwang,4 Jung-Der Wang,1,3 Che-Yen Chuang,1 and the Division of AIDS and STD, Center for Disease Control, Department of Health, Executive Yuan.
  8. 8. New HIV and Syphilis in BC 0 5 10 15 20 25 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 HIV Syphillis Rateper100,000population M REKART, BC-CDC, 2006
  9. 9. 0 100 200 300 400 500 600 700 0 1 2 3 4 5 6 7 8 24 months Baseline Plasma Viral Load (log10 copies/mL) Distribution V Dias Lima et al. Unpublished; 2006. Impact of HAART in BC-CfE Frequencyofpeople
  10. 10. V D Lima et al JID July 1st 2008
  11. 11. R2 = 0.90 R2 = 0.97 0 500 1000 1500 2000 2500 3000 3500 4000 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Date NumberofParticipants Model DTP Poly. (Model) Poly. (DTP) p-value = 0.6423 R2 = 0.85 R2 = 0.73 0 100 200 300 400 500 600 700 800 900 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Date HIVIncidence(N) BC-CDC Model Poly. (BC-CDC) Poly. (Model ) p-value = 0.5579 V D Lima et al JID July 1st 2008
  12. 12. Adherence: 0% - <40% Guideline: ≤200 cells/mm3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100% Coverage: Current Adherence: 78.5% Guideline: ≤200 cells/mm3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: Adherence: 80% - <95% Guideline: ≤200 cells/mm3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: Adherence: 95% - 100% Guideline: ≤200 cells/mm3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: Adherence: 0% - <40% Guideline: ≤350 cells/m m3 100 150 200 250 300 350 400 450 500 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100% Coverage: Current Adherence: 78.5% Guideline: ≤350 cells/mm 3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: Adherence: 80% - <95% Guideline: ≤350 cells/m m3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: Adherence: 95% - 100% Guideline: ≤350 cells/m m3 100 150 200 250 300 350 400 450 500 550 1995 2000 2005 2010 2015 2020 2025 2030 2035 Year NumberofNewInfections 50% 75% 90% 100%Coverage: CD4 200/mm3 Adh <40% CD4 200/mm3 Adh 40 - 80% CD4 200/mm3 Adh 80 - 95% CD4 200/mm3 Adh 95 - 100% CD4 350/mm3 Adh <40% CD4 350/mm3 Adh 40 - 80% CD4 350/mm3 Adh 80 - 95% CD4 350/mm3 Adh 95 - 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% 50% 75% 90% 100% V D Lima et al JID July 1st 2008
  13. 13. Impact of HAART on Viral Load at the Population Level in BC
  14. 14. Community plasma HIV RNA among a cohort of injection drug users in Vancouver Whiskers represent 95% confidence intervals. Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008
  15. 15. Community plasma HIV RNA levels and HIV incidence among two parallel cohorts of IDUs HIV incidence is expressed as incidence density per 100 person years. Whiskers represent 95% confidence intervals. Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008
  16. 16. Cox proportional hazards regression of the time to HIV infection among 1,048 HIV negative IDUs followed between May 1, 1996 and Dec 31, 2004. Characteristic Relative Hazard 95% Confidence Interval p-value Community Viral Load Per log10 increase 9.40 (4.28 Š 20.64) < 0.001 Unsafe sex Yes vs No 0.82 (0.56 Š 1.21) 0.360 Used syringe borrowing Yes vs No 1.70 (1.15 Š 2.51) 0.008 Ethnicity White vs Other 0.55 (0.39 Š 0.78) < 0.001 Heroin injection > Daily vs < daily 1.19 (0.83 Š 1.70) 0.349 Cocaine injection > Daily vs < daily 2.88 (1.99 Š 4.17) < 0.001 Unstable housing* Yes vs No 1.40 (0.98 Š 2.02) 0.067 Plasma HIV R NA was time updated based on median value in the BART cohort during the 6 month period prior to each HIV-negative participantÕsfollow-up visits; ą Defined as insertive or receptive vaginal or anal intercourse; *Defined as living in a single room occupancy hotel, shelter, recovery or transition house, jail, on the street, or having no fixed address; Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008
  17. 17. Estimated HIV burden in B.C.
  18. 18. 0 1000 2000 3000 4000 5000 6000 7000 8000 HIV+ (Est) HIV+ Aware HIV+ HAART Eligible HIV+ on HAART HIV+ Eligible not on HAART Estimated HIV burden in B.C. (2006) Non IDU IDU
  19. 19. HIV among Injection Drug Users BC - 2006 - n=4770 0 1000 2000 3000 4000 5000 6000 HIV+ Total (Est) HIV+ Aware HIV+ HAART Eligible* HIV+ on HAART HIV+ Eligible* not on HAART * Based on a CD4 Cell count ≤ 200/mm3
  20. 20. QuickTime™ and a decompressor are needed to see this picture.
  21. 21. Cumulative all-cause (A) and non-accidental (B) mortality rate among 3116 antiretroviral-naïve patients initiating HAART Highly Active Antiretroviral Therapy and Survival in HIV-infected IDUs. Wood E, Hogg R, Dias Lima V, Kerr T, Yip,B, Marshall B, and Montaner J. JAMA, 2008, in press
  22. 22. A Proposal to Evaluate the Impact of Expanding HAART on HIV Incidence among Injection Drug Users in British Columbia Intervention 3 years Primary Endpoint HAART Expansion HIV Incidence* within 2008 guidelines Seconday Endpoints: mortality and morbidity HIV-1-RNA Levels HIV resistance CD4 cell counts adverse events and safety labs hospitalizations resource utilization adherence to HAART * Primary analysis = HIV incidence pre-HAART expansion vs year 3
  23. 23. Expansion of HAART for HIV Prevention: Challenges  Untested hypothesis  Safety/toxicity  Individual rights  Resistance  Hidden epidemics  Logistics  Erosion of prevention effort  Cost This hypothesis needs to be urgently explored
  24. 24. Expansion of HAART for HIV Prevention: Challenges  Untested hypothesis  Safety/toxicity  Individual rights  Resistance  Hidden epidemics  Logistics  Erosion of prevention effort  Cost This hypothesis needs to be urgently explored However, our goal is to characterize changes in HIV incidence resulting from expanding HAART use within those in medical need
  25. 25. Seek and Treat to Optimally Prevent HIV & AIDS in Injection Drug Users STOP HIV & AIDS in IDUSTOP HIV & AIDS in IDU QuickTime™ and a decompressor are needed to see this picture.

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