hiv: history current status and future
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HIV: HISTORY CURRENT STATUS AND FUTURE. John G. Bartlett Johns Hopkins University School of Medicine Conflicts -- None. HIV REVIEW History Current standards Future. HIV NATURAL HISTORY. HIV transmission ↓ 2- 4 weeks Acute HIV (50 – 90 %) ↓ 1- 3 weeks Asymptomatic - PowerPoint PPT PresentationTRANSCRIPT
HIV: HISTORYCURRENT STATUS AND FUTURE
John G. BartlettJohns Hopkins University
School of Medicine
Conflicts -- None
HIV REVIEW
HistoryCurrent standards
Future
HIV NATURAL HISTORY
HIV transmission↓ 2- 4 weeks
Acute HIV (50 – 90 %)↓ 1- 3 weeks
Asymptomatic ↓ 8 years
AIDS ↓ 1.3 yearsDeath
HIV RISK CATEGORIES (2010)CDC data – 48,298 cases
MSM (gay men) – 63%Injection drug use – 8%Heterosexual transmission – 25% Blood transfusions – 0% Perinatal transmission – (162)African American – 44%Poverty – 2.1% (8 x ↑)
HIV: HISTORY 1981-2013
1981: PCP Cluster 1994: ACTG 0761982: “AIDS”named 1996: Vancouver IAS – “HAART”1983: HIV reported 1997: FDA accepts Viral Load as
end point1985: Serologic test 2003: PEPFAR born1986: AZT trial 2008: First cure1987: Act-up 2012: Prevention and cure1990: Ryan White Act 2013: “AIDS-free generation” –
Hilary Clinton1991: Magic Johnson
CDC: MMWR June 5, 1981 9 MSM with PCP
CDC: MMWR July 3, 1981
HIV/AIDS – FIRST DECADE
HIV: Circa 1981-91Patients: Most died• Diarrhea• Dementia• Disgrace• Image: IDU & MSM• Fear: Contagion• Untreatable
WHO WINNING PHOTO AWARD:AIDS – THE HUMAN TRAGEDY
ID/IMMUNOLOGY:Wegener disease & polyarteritis
nodosa; Director of NIAID
Anthony Fauci“Goose pimples” 1981
1984 Ryan WhiteChild with hemophilia –
HIV discovered 12/17/84 – banned from school and given 6 month diagnosis. Died 5 years later, 4 months before passage of the Ryan White Care Act – now $2 billion/year for HIV drugs for 500,000. Bono – “Greatest man I ever met”
C. Everett Koop“The Letter” 1987
Surgeon General under President Reagan
Champion of – Sex educationCondomsHandicapped childrenCigarette harm“The Letter” was an AIDS
wakeup call
AIDS QUILT – 1987
Panel are 3’ by 6’ with tributes to people who were lost to HIV → Washington Mall 1987-1996, weight = 54 tons, 94,000 names (20%)
AIDS COALITION to UNLEASH POWER: 1987
Civil disobedience: Wall Street 1987, NY Post Office 1987, St. Patrick’s Cathedral
1989, NIH 1990 (Now TAG)
Martin DelaneyActivist (without AIDS)
1945-2008
Founded Project Inform “for medically supervised guerrilla trials” – Major force in NIAID, FDA and
ethics
The Trial: AZT vs. placebo (n=282). DSMB stopped study: 19 deaths (placebo) vs. 1 (AZT)
(Fischl MA. NEJM 1987;317:185)
Jeff Murray, MDDeputy Director
Division of Antimicrobial Drug Products for FDA
Major facilitator of HIV drugs (n=28) and, more recently HCV (#24 in trials)
MAGIC JOHNSONThe Announcement: 1991
“I have AIDS”(Trumped efforts of millions to destigmatize HIV
infection)
PROTEASE 1996
The development of protease inhibitors and beginning of HAART
■ IDV / 3TC / AZT
● IDV
∆ AZT / 3TC
THE STUDY THAT CHANGED AIDSGulick RM. Merck 035 NEJM 1997;337:734
HAART: IDV/AZT/3TCResults for NDV at 52 weeks – 80% vs. zero
David Ho
“Hit hard and hit early” …Time Magazine: Man-of-the-year, 1996
Mortality From 1990-2004 in the Johns Hopkins HIV Clinical Cohort
Lau B, et al. Non-AIDS Related Mortality Risk Exceeds AIDS-related Mortality Among Injecting Drug Users with CD4+ Counts Above 200 Cells/mm3. CROI Denver, CO, 2006
NRTI NNRTI PI El CCR5 II1987 AZT ------ ------ ------ ------
------1991-92 ddI, ddC ------ ------ ------ ------ ------1995 d4T ------ ------ ------ ------
------1996 3TC ------ SQV ------ ------ ------1997 ------ NVP RTV, IDV ------ ------
------1997 ------ DLV NFV ------ ------ ------1998 ------ EFV ------ ------ ------
------1999 ABC ------ APV ------ ------
------2000 ------ ------ LPV ------ ------
------2001 TDF ------ ------ ------ ------
------2003 FTC ------ ATV ENF ------
------2005 ------ ------ TPV ------ ------
------2006 ------ ------ DRV ------ ------
------2007 ------ ------ ------ ------ MVC
RAL2008 ------ ETR ------ ------ ------
------2011 ------ RPV ------ ------ ------
------2012 ------ ------ ------ ------ ------
EVG2013 ------ ------ ------ ------ ------
DTG
HIV SCIENCE AND CARE1996-2013
US & Europe (“Resource Rich”)1. Fine tuning 1996-now2. Treatment “done” – 2008 (Fauci)3. New priorities:
• International• Domestic: Cure & Prevention
International (“Low Resource”)4. Resource limits: Drugs5. Infrastructure for chronic care6. WHO – Plan universal ART when
resources allow
President Bill ClintonState of the Union Speech: 2000
“AIDS in Africa is so devastating – it threatens the social, political and economic stability of the world”
↓ Clinton Foundation (2001) • Low cost drugs • Pediatric HIV
Subsaharan Africa:12% global population
69% of HIV cases
CLINTON FOUNDATION 2002-
2002 2012
Art:Cost/yr $12,000 $100-200
No. on ART 20,000 6,000,000
President George W. BushPEPFAR: 2002
Bush: Do those HIV drugs work?
O’Neil: “Let me tell you about my morning in the Moore Clinic”
Bush: “Tony , we need to do something, Think big – really big”
President George W. Bush
Fauci: “Thinking big”Collaborators –
M. Dybul,P. Mugyeni, E. Goosby, J.W. Pape
Plan Proposed: Would be considered
January 2003: “Seldom have we been offered the opportunity to do so much for so many”
Peter Mugyeni and Laura BushState of the Union Address
Bush: “$15 billion for Africa”Mugyeni: Jumped up → cheered →
hugged the First Lady
Bono: “PEPFAR – Greatest act of heroism since we jumped into WWII” NYTimes 12/1/11
Need to put banner Prominent Voices to Address AIDS 2012
Leaders from the worlds of science, diplomacy, politics, philanthropy and entertainment are speaking at AIDS 2012, including:
• President Bill Clinton • U.S. Secretary of State Hillary Rodham Clinton • U.S. Secretary of Health and Human Services Kathleen Sebelius • South African Deputy President Kgalema Motlanthe • Former U.S. First Lady Laura Bush • HRH Mette-Marit, Crown Princess of Norway • World Bank President Jim Yong Kim • UNAIDS Executive Director Michel Sidibé • Nobel Laureate Françoise Barré-Sinoussi • NIAID Director Anthony Fauci • Philanthropist Bill Gates • Humanitarian Elton John • Actress Whoopi Goldberg
Hillary Rodham Clinton2012 IAS Conference – Washington DC
“Blueprint for an AIDS-free generation”
HIV REVIEW
HistoryCurrent standards
Future
HIV TREATMENT (DHHS & IAS-USA)
Test: All persons age 13-64 yrs yrs(CDC); annual if risk
Treat: Everybody with HIVWhat: TDF/FTC or ABC/3TC plus
EFV, DRV/r, ATV/r, RALMonitor: VL, CD4, etc.Change: VL >200 or ADR
LIFE EXPECTANCY – DENMARKHelleberg M. CID 2012 [in press]
35 year old man HIVHIV Smokes Survivalo o 78.4 yrs+ o 73.3 yrso + 66.1 yrs+ + 62.6 yrs
HIV CARE AND RESEARCH1983-1996 2005-2013
Care: OIs, PCP, CMV, MAC, KS, Crypto
Care: CVD, Lipids, DM, HBP, Bones
Neuro: Dementia, Neuropathy Neuro: Dementia
Psych: Depression Psych: Variable
Patients: Stigma Patients: Same
Provider: Burn-out Provider: Is it a specialty?
Research: Vaccine and Treatment Research: Immune activa- tion, prevention
HIV REVIEW
HistoryCurrent standards
Future
HIV: THE FUTURE (US)
Research priorities• Treatment – done (2008)• Prevention• CureOperational challenges• Care delivery: 28% have controlled HIV
viremia• Who will be primary provider (Is this a
specialty• Healthcare reform
TransmissionHIV transmission efficiency correlates with Viral Load – No transmissions with VL <1500 c/mL (2000)
Transmission efficiency• 1/900 coital acts• M→F & F→M near equal• Maximum risk in primary HIV
Treatment for prevention• HPTN 052 (2012)• Changed Global policy
Never been a confirmed case with sexual transmission (BMHIVA) (2013)
Quinn T. NEJM 2000;342:921
HIV TREATMENT FOR PREVENTION:HPTN 052 M. Cohen (PI)
(Cohen MS. NEJM 2011;365:493)
Protocol: Discordant couples, CD4 350-550: Randomized to ART vs. no ART until CD4 <250
Results: N=1,763 (M=890, F-873)ART No Artn=886 n=877
HIV transmission* 1*** 27** *Linked cases (28 transmissions unlinked) **Protection with ART = 96% -- Study continues to determine durability***Single exception preceded viral suppression
HPTN 052: The study that changed HIV global strategy
Treatment as Prevention: Effect of ART Coverage on HIV Incidence in Rural South Africa(Tanser F. 2012 CROI;Abstr. 136LV)
• Annual population based HIV surveillance in rural KwaZulu-Natal• 2004 – 2011: 1395 HIV seroconversions among 16,588 HIV negative
adults ≥15 years of ageAdjusted HIV Infection Rate by ARV
Coverage CategorySpatial Estimates of Proportion of HIV
Patients on ART
P=0.590
P=0.002
P<0.001 P=0.015
2007 2008 2009
2010 2011
<10%
10-20%
20-30%
30-40%
>40%
Tanser F, et al. 19th CROI; Seattle, WA; March 5-8, 2012. Abst. 136LB.
Efficacy of Daily OralFTC/TDF PrEP
Trial Pop. Efficacy 95% CI
iPrEx MSM 42% 18 to 60%
Partners PrEP Men 83% 49 to 94%
Women 62% 19 to 82%
TDF2 Men 80% 25 to 97%
FemPrep* Women 49% -22 to 81%
VOICES* women TDF only arm discontinued
Candidates: High risk MSM and discordant couplesFDA approved TDF/FTC for PrEP July 2012 .
“The Berlin Patient”
• HIV + leukemia → chemotherapy and stem cell tx → 5 yrs; No HIV detected (R. Siliciano)
• 2012: 2 more patients – Brigham Hospital, Boston(IAS Conference 2012)
The “Gardner Cascade”(Gardner EM. CID 2011;52:793)
Estimated 14% have viral suppression!!
MAKE IT EASYSensitivity: 93%• Specificity: 99.8%• Distribution:
Walmart, CVS, Walgreens, RiteAid, Kroger, etc.
P4P4P: THE STATUS OF PAYING PATIENTS FOR SELF CARE
Practice: Widespread and internationalIncentives: Cash, groceries, lottery tickets, meal
tickets.Conditions: Chronic – smoking, obesity , BP
control, diabetes, HIVHIV trial: HPTN 65 – Controlled trial, (unblinded)
HIV test – $25, Enroll in care – $70, NDV – $280/yr (1.7% of HIV care cost)
Status: Widely practiced, no one wants to talk about it. Adherence guidelines refused (Ann Intern Med 2012;156:817)
A TEST OF FINANCIAL INCENTIVES TO IMPROVE WARFARIN ADHERENCE
(Volpp KG. BMC Health Sys Res 2008;8:272)
COST OF CAREContemporary costs/yr.(AIDS 2010;24:2705)• HAART – $12,000 (72%)• Meds – other – $2,100• In-patient – $600• Out-patient – $400 (2%)Total (Meds) – $16,600Generic 3TC/EFV +TDF: Reduce cost
$6K/yr=$1B – BUT 3 pills/d(Walensky R. Ann Intern Med 2013;158:84)
HIV WITH 2013 HEALTHCARE REFORM
SUMMARYHistory: GloriousFailure: Vaccine and cureChallenge: Care delivery, prevention
and costFuture: Who will provide HIV care and
who will payExpectation: Diabetes model