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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
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5. Effect of HAART on HIV
Transmission
• MTCT
• Discordant Couples
• Ecological Evidence
6. The Impact of HAART on MTCT
USA, 1985 - 2000
Canada, 1990 - 2004
7. 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
8. 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.
9. 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
10. 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 Unpublished; 2006.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
15. 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
16. 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
17. 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
20. 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
22. 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
23. 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
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
25. 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
26. Seek and Treat to Optimally Prevent
HIV & AIDS in Injection Drug Users
STOP HIV & AIDS in IDUSTOP HIV & AIDS in IDU
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