kristin m. wall , phd kmwall@emory department of epidemiology
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www.aids2014.org
From efficacy to effectiveness: HIV seroincidence by ART status
among HIV discordant couples in Zambia
Kristin M. Wall, PhD
kmwall@emory.edu
Department of Epidemiology
Rwanda Zambia HIV Research Group
Emory University, Atlanta, GA, USA
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Conflict of Interest Disclosure
The authors have no conflicts of interest due to financial or personal relationships that might be perceived to cause bias.
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Acronyms for this talk
TasP: Antiretroviral treatment (ART)-as-prevention• For the purposes of this talk, ART has been provided for
therapeutic reasons only
CVCT: Couples’ voluntary HIV counseling and testing• Joint pre-test counseling• Rapid HIV testing• Joint post-test counseling
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Research evidence
Recommendations
Implement and analyze
Questions
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Research evidence
Recommendations
Implement and analyze
Questions
CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)
TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)
www.aids2014.org
Research evidence
Recommendations
Implement and analyze
Questions
CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)
TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)
CVCT WHO, 2012 (Recs 1-3)
TasP WHO, 2012 (Recs 5)
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Research evidence
Recommendations
Implement and analyze
QuestionsCVCT: WHO Recs 1-3TasP: WHO Rec 5(WHO, 2012)
Real-world TasP effectiveness in discordant couples?
CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)
TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)
CVCT WHO, 2012 (Recs 1-3)
TasP WHO, 2012 (Recs 5)
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Research evidence
Recommendations
Implement and analyze
Questions
Real-world TasP effectiveness in discordant couples?
ART adherence?
ARV resistance?
CVCT WHO, 2012 (Recs 1-3)
TasP WHO, 2012 (Recs 5)
CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)
TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)
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CVCT scale-up in government clinics
HIV prevalence, 15-49 year olds (DHS)
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Impact of CVCT on HIV transmission in a real-world setting
82% reduction in transmission after CVCT
RR 0.2 (95% CI 0.1-0.4)
69% reduction in transmission after CVCT
RR 0.3 (95% CI 0.2-0.6)
Cost of preventing one HIV infection with CVCT
in Zambia$392
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82% reduction in transmission after CVCT
RR 0.2 (95% CI 0.1-0.4)
Impact of CVCT on HIV transmission in a real-world setting
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73% reduction in transmission after CVCT
RR 0.3 (0.1-0.6)
83% reduction in transmission after CVCT
RR 0.2 (95% CI 0.1-0.4)
$666 to prevent one HIV infection
Teasing apart the effects of CVCT and TasP
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CVCT is effective in a real-world setting• Irrespective of preceding therapeutic ART use
– 70-80% reduction in HIV incidence, $400-$700 per infection averted
TasP is not as effective in real-world settings as in a trial among serodiscordant couples who:• Have NOT been tested and counseled together
– 30% reduction among those on therapeutic ART
Conclusions
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Future Questions: ART Adherence?
How much can retention
and adherence improve
when ART patients are
counseled with their HIV-
spouses?• ART NON-adherence: 40%1-2
• ART attrition at 1 year: ¼ 3-4
1. Sasaki et al, An Clin Mic Antimicro, 2012; 2. Birbeck, AJTMH 2009; 3. Scott et al, BMC Pub Health 2014; 4. Fox et al, TMIH, 2010
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Future Questions: ARV Resistance?
Were ARV resistant
viruses transmitted?
• ARV resistance:1-2 – 5-6% of ART naïve
1. Price et al 2011; 2; Hamers et al, JAIDS, 2010http://hivdb.stanford.edu/surveillance/map/
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Recommendations
CVCT should be promoted and provided in all settings that offer HIV testing (WHO 2012 Recommendations 1-3 of Couples’ HIV Counseling Guidelines), including:– Antenatal clinics– PITC– Community-based VCT– Household VCT
CVCT should be a priority in ART clinics (WHO 2012 Recommendation 4 of Couples’ HIV Counseling Guidelines)
Resource allocation models should include CVCT and TasP– Using real-world estimates of effectiveness
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Acknowledgements
Rwanda Zambia HIV Research Group (RZHRG) Contributors
Mubiana Inambao
M. Kakungu Simpungwe Rachel Parker
Joseph Abdallah
Nuri Ahmed
William Kilembe
Amanda Tichacek
Elwyn Chomba
Gordon Streeb
Susan Allen
Arise—Enhancing HIV Prevention Programs for At-Risk Populations
Ibou Thior
Julie Pulerwitz
Zambian Ministry of Health & District Health Management Team
CVCT Clients & Clinic Staff
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Support for this project was provided by the Canadian Government through PATH and the Department of Foreign Affairs Trade and Development. The views expressed by the authors do not necessarily reflect the views of PATH, the Canadian Government or the Department of Foreign Affairs Trade and Development. This document was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.
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Other RZHRG posters/presentations supported by PATH-Arise
Posters• TUPE167 • TUPE368 • WEPE 435• WEPE 206
Oral poster • THAC0504
Oral abstract• THPDE0104
Arise Satellite Session, Thursday July 24th, 18:30-
20:30 in Plenary 3
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