Continuum of Care

HIV/AIDS Treatment Cascade

Presenter:

Arismendi A. Jimenez, MD

Vice President, Global Capacity Building

Cicatelli Associates Inc.

Disclosure

The following people have no relevant financial, professional or personal relationships to disclose:

Faculty:

Arismendi A. Jimenez, MD

CNE Program Planner(s):

Melanie Steilen, RN, BSN, ACRN

Iris Stendig-Raskin, MSN, CRNP, WHNP-BC

CNE Program Reviewer:

Iris Stendig-Raskin, MSN, CRNP, WHNP-BC

There are no commercial supporters of this activity.

LEARNING POINTS

• Review the continuum of care HIV/AIDS care

(treatment cascade)

• Discuss the implications of its findings and how it

affects the patients and public health

• Describe the impetus for action in each critical

junction of the cascade

The history of the AIDS

global pandemic began in

illness, fear, and death

IN TIME PROGRESS WAS MADE

• Public awareness

• Testing technology

• Treatment availability

• New medications

• Funding

1 in 4 People with HIV are taking HIV medicine regularly and have

their virus under control.

1.2M People in the US are living with

HIV.

1 in 5 People with HIV

don't know they are infected, don't get HIV medical care, and can pass the virus onto others without knowing it

Continuum of Engagement in Care

Source: U.S. Department of Health & Human Services Cheever 2007

2011: The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection. Edward M. Gardner, ;Margaret P. McLees ;John F.

Steiner ;Carlos del Rio, and William J. Burman

CONTINUUM OF CARE HIV/AIDS TREATMENT CASCADE (CDC)

WHY IS THE HIV CARE CONTINUUM

IMPORTANT?

FAILURES • Late diagnosis

• Non linkage

• Flawed linkage

• Insufficient ART

• Non ART Adherence

20% unaware of their HIV

status.

Many of which are acutely infected

account for most of the new infections

USING MARKS MODEL AND 2008 CDC DATA

ESTIMATING IMPACT OF KNOWLEDGE OF HIV INFECTION

ON SEXUAL TRANSMISSION OF NEW HIV INFECTIONS

~25% Unaware of

Infection

~75% Aware of Infection

~54 % of New

Infections

~46% of New Infections

Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50

Knowledge of HIV Infection New HIV Infections

• Basic risk of transmission

• when the person is unaware of HIV Status 3 times more risky (Marks, et al; 2006)

• 26 times more risky if the person is in the acute state of infection. (Hollingworth, et al; 2008)

TOWERS OF RISK

0

5

10

15

20

25

30

Basic Risk Unaware Acute Infection

DURING THE ACUTE STAGE

A person is between

100 and 3,000 times

more infectious than

persons in the later

stages of HIV infection

1. Kahn JO, et al 1998; 2. Quinn TC, et al 2000 3. Jacquez JA, et al 1994

HIV SCREENING CAN BE IMPROVED…

Potential AIDS Defining Event

Number HIV Screening Rate (%)

Burkit Or Immunoblastic Lymphoma Or Primary Lymphoma Brain 2980 3.0

Encephalopathy 2066 5.0

Invasive Cervical Cancer 958 4.4

Candidiasis Of Bronchi, Trachea, Lung , Esophagous 542 7.0

Histoplasmosis, Disseminated, Extra pulmonary 370 2.2

Wasting/ cachexia 350 4.3

PNEUMOSISTIS CARINII PNEUMONIA 48 10.4

KAPOSI SARCOMA 35 8.6

Source: SAY YES TO THE TEST. New York State Department Of Health 4 / 13 Compiled from administrative claims data from 8 US plans national sample of commercially insured patients who where screened

Unsafe sexual Behavior is reduced substantially

after people become aware they are HIV Positive

Overall reduction in

unsafe sex

Reduction in unsafe sex

(amongst sero-discordant

partners)

Say Yes to the Test, NYS Department of Health 4/13

53% Reduction

68% Reduction

EARLY DETECTION AREAS OF NEED

• Expanding Testing Programs

– Specialty care practices

– Non traditional settings

– Pharmacy based testing initiatives

• Reduction Of Stigma

– Offering Testing Routinely

– Improve screening of early HIV infection

LINKAGE TO CARE

AND EARLIER TREATMENT

• HPTN 052 trial: 96% reduction in HIV transmission

• 41% reduction in clinical events when treatment

started earlier

COMMUNITY VIRAL LOAD

HIV

HIV

HIV

NO HIV TREATMENT MEANS: INCREASE INDIVIDUAL VIRAL LOAD

AND WITH THAT ALSO INCREASED COMMUNITY VIRAL LOAD

Individual Community

San Francisco

24 November 2010 NAT Treatment as Prevention Das-Douglas, CROI 2010, abstract #33

Why help in Linking people to Treatment:

– Lowering the amount of virus can keep a person with

HIV healthy longer.

– Keeping the virus under control with medicines greatly

lowers the chances of passing HIV.

– The number of people with HIV who get AIDS has

decreased. Still, more than 16,000 people with AIDS

die each year.

6.4 6.6 6.8

7 7.2 7.4 7.6 7.8

8 8.2 8.4

Life expectancy no

HIV

HIV positive no early Dx &

Tx

Positive early Dx & Tx

Series 1

Fumiyo Nakagawa UCL Medical School, 2011

British study of Life expectancy of HIV-positives

Thinking of Treatment as Prevention:

Improving testing and linkage to care

Suthar et al, Plos Med 2013 [Accepted] Global Update on HIV treatment, WHO, 2013

• Partner and couples testing; Community testing; Self-testing; Combination testing; linking to care

– Married for 29 years, 3 children, public school teacher; husband and her

active in their community.

– Non-smoker; no known history of substance use.

– Felt sick with severe and persistent cough and difficulty breathing. With her

physician office closed, Anne went to the Emergency Department of her local

office where she received antibiotics and was kept overnight for observation

– The next morning her condition was still declining. A bronchoscopy reveal

Pneumocystis jiroveci. That triggered her physician to test her for HIV. The

result was positive

– Despite rapid initiation of appropriate treatments Anne’s condition continued

to decline and she died 2 days later. Post mortem lab results showed 21 CD4

cells and a viral load of 240,000 copies

MEET ANNE:

DID NOT APPEAR TO BE AT RISK FOR HIV

AT LEAST 18 TIMES OVER MANY YEARS, ANNE COULD HAVE BEEN TESTED BUT WASN’T

* Hypothetical patient profile

Source: SAY YES TO THE TEST. New York State Department Of Health 4 / 13

*

Video Review:

Treatment Cascade

HIV-free Generation Campaign

Vision for the National HIV/AIDS

Strategy

The United States will become a place where

new HIV infections are rare and when they do

occur, every person regardless of age, gender,

race/ethnicity, sexual orientation, gender identity

or socio-economic circumstance, will have

unfettered access to high quality, life-extending

care, free from stigma and discrimination

Thanks for your attention

Now…Let’s Roll !