This document discusses whether treatment of HIV as prevention can end the HIV epidemic. It summarizes the treatment cascade showing that many people living with HIV are not engaged in care or virally suppressed. It also discusses how expanded access to HIV treatment and care can reduce transmission at both individual and population levels by suppressing viral loads. However, it notes challenges like lack of access to HIV care and waiting lists for assistance programs in the US. The document advocates for a "synergistic prevention" approach combining biomedical and behavioral strategies to urgently reduce HIV incidence.

1. David Holtgrave, PhD
HIV Treatment as
Professor and Chair
Prevention:
Dept. of Health, Behavior &
Is this the end of HIV? Society

2. AS A NATION, DO WE
AND WILL WE PROVIDE
NECESSARY HIV CARE
AND TREATMENT?
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3. Gardner treatment cascade
From: Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for
prevention of HIV infection. Clin Infect Dis. 2011 Mar 15;52(6):793-800.
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4. CDC MMWR, November 30, 2011
From: Vital Signs: HIV Prevention Through Care and Treatment — United States. MMWR. 2011;60:47. 1618-1623.
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5. ADAP Waiting Lists are the
Tip of the Iceberg
http://coastal.er.usgs.gov/ocean-
acidification/arcticcruise2011/journal/index.php/2011/08/20/icebergs/
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6. In 2004, IOM Panel calls for HIV care entitlement program…
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7. “COMBINATION PREVENTION”
HAS SADLY BECOME
“SUBSTITUTION PREVENTION”
WHEN WE NEED
“SYNERGISTIC PREVENTION”
TO URGENTLY IMPACT INCIDENCE
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8. HIV is transmitted during an act of
unprotected risk behavior in a serostatus
discordant partnership with virus present
Unprotected transmission No unprotected
In a serostatus discordant
relevant risk behavior transmission relevant risk
partnership…..
present behavior
Concentration of Essentially no transmission
Unsuppressed Viral Load
transmission
Essentially no transmission
Suppressed Viral Load Essentially no transmission
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9. Key US populations defined by HIV serostatus and relevance
of various treatment-related prevention approaches
From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub
ahead of print].
9 © 2009, Johns Hopkins University. All rights reserved.

10. Number of forward HIV transmissions from
subgroups of persons living with HIV, and potential
points of prevention intervention
From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub
ahead of print].
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11. Key services needs of the three
subpopulations of persons living with HIV
From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub
ahead of print].
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12. Incidence of HIV under various scenarios
Incidence
70000 Flat TR Comparator
60000 S694YMC
Incidence
50000 S694YFSC
40000 S694NMC
30000
S694NFSC
20000
S807YMC
S807YFSC
12
16
10
14
18
20
20
20
20
20
20
20
S807NMC
Year
S807NFSC
Holtgrave et al., under review (please do not reproduce)
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