hiv treatment as prevention for pwids: lessons learned and implications for hcv
DESCRIPTION
HIV Treatment as Prevention for PWIDs: Lessons Learned and Implications for HCV. Frederick L. Altice, M.D., M.A. Director of Clinical and Community Research Schools of Medicine & Public Health Yale University. Global HIV Epidemic Among PWIDs. - PowerPoint PPT PresentationTRANSCRIPT
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HIV Treatment as Prevention for PWIDs:Lessons Learned and Implications for
HCV
Frederick L. Altice, M.D., M.A.
Director of Clinical and Community Research
Schools of Medicine & Public Health
Yale University
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Global HIV Epidemic Among PWIDs
● Outside of Sub Saharan Africa, 33% of all new HIV infections are among PWIDs
● From 2001 to 2011, new annual HIV infections decreased from 3.2 to 2.5 million annually (-22%)
- Most reductions occurred in Sub Saharan Africa
- +25% in Eastern Europe, Central and SE Asia – low ART coverage!
● In countries where HIV incidence is increasing, 70% to 80% of HIV cases are among PWIDs
● Where comprehensive HIV prevention packages for PWIDs exist, HIV transmission has
UNAIDS, HIV/AIDS Global Report, 2012; Europe WHO, 2012; Mathers et al, Lancet, 2008.
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Evidence-Based Strategies to Reduce HIV Transmission Among PWUDs
NSP
MAT
HIVC&T
PrEP
Primary & Secondary Secondary Only
ART
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Treatment as Prevention Can Work Among PWIDs, but …..
● Ecological studies in Vancouver and Baltimore have documented reduced transmission among PWIDs where community VL has decreased
● The HIV Continuum of Care for PWUDs is not equal to their non-drug using counterparts
- HIV diagnosis
- Linkage to care
- Retention in care
- Receipt of ART
- ART adherence
- Viral Suppression
Differs based on local context and funding priorities (LMICs? and global fund coverage)
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Engagement in Care Among HIV+ PWIDs in Baltimore, ALIVE Cohort, 1998-2011
Ful
ly R
etai
ned
(30.
5%)
Con
tinuo
usly
on
AR
T (
17.3
%)
Sus
tain
ed V
L<40
0 (8
.0%
)
Westergaard, AIDS 2013
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Engagement in Care Among HIV+ PWIDs in Baltimore, ALIVE Cohort, 1998-2011
Poor Retention in Care
● Active drug injection
● Incarceration
● No health insurance
● No usual site of care
● Lack of consistency in HIV care provider
Poor Viral Suppression
● Active drug injection
● Alcohol use
● Crack cocaine use
● Incarceration
● Lack of consistency in HIV care provider
● Decreasing CD4 countWestergaard, AIDS 2013
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Altice FL et al, JAIDS, 2011
Integrating Buprenorphine Into HIV Clinical Care Settings – Retention!Prescribed ART Viral Suppression
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Treatment of HIV-Infected Persons for Prevention of HIV Transmission
Westergaard RP, J Int AIDS Soc, 2012
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Withholding HIV Treatment sThe Malaysian Context
Ferro E, IAS 2013
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Organization of Healthcare Delivery for HIV+ PWIDs Matters (Ukraine)
Bachireddy C, Drug Alcohol Depend, 2013 Bachireddy, DAD, 2013
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Incarceration: High Risk Transmission Environment Among HIV+s (Ukraine)
Mean number of people sharing
among injectors = 4.4 (0-30)
Mean number of people sharing
among injectors = 4.4 (0-30)
Izenberg et al, IJDP, 2004
Only 19.4% received
ART
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Retention in Care Among HIV+ Jail Detainees: Results from a Multi-Site Study (N=867)
Althoff, AIDS Behav, 2013
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HIV+ Jail DetaineesHeightened Instability Post-Release
MaleFemale
Meyer JP et al, AJPH, 2014
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Interventions to Improve ART Adherence Among People with SUDs
AIDS & Behavior, 2013
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Evidence-Based Retention and Adherence Interventions for PWUDs
● Directly administered antiretroviral therapy (DAART)
- Costly, time intensive, inconvenient for some
● DAART integrated into methadone treatment
- Inadequate numbers on MMT, impact of take-home doses
● Provision of opioid substitution therapy with methadone or buprenorphine
- Low OST coverage in many countries that need it
● Integration of health services
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Perfect
Alcohol & Adherence: Peruvian MSM
Ferro E et al, IAS 2013
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PrEP Trials Are Efficacious in MSM, Heterosexuals, and PWIDs
Trial Population/Setting Intervention
HIV Infections, n HIV Risk Reduction, % (95% CI)PrEP
Placebo
iPrEX[1] (N=2499)
MSM, transgender women, 11 sites in US, South America, Africa,
Thailand
TDF/FTC 36 64 44 (15-63)
Partners PrEP[2] (N=4747)
Serodiscordant couples in Africa
TDF 13 52 75 (55-87)
TDF/FTC 17 67 (44-81)
TDF2[3]
(N=1219)Heterosexual males and
females in BotswanaTDF/FTC 10 26 62 (16-83)
Thai PWID[4] (N=2413)
PWIDs from 17 drug treatment centers in
Thailand
TDF 17 33 49 (10-72)
1. Grant RM, et al. N Engl J Med. 2010;363: 2587-2599. 2. Baeten JM, et al. N Engl J Med. 2012;367:399-410. 3. Thigpen MC, et al. N Engl J Med. 2012;367:423-434. 4. Choopanya K, et al. Lancet. 2013;381:2083-2090.
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Adherence: Key Contributor to Outcome in PrEP Trials (Detectable TDF Levels)
1. Grant RM, NEJM, 2010; 2. Baeten JM, NEJM, 2012; 3. Choopanya K, Lancet. 2013.
Differences in Adherence Translated to Relative Risk Reduction in Transmitting HIV
92% 90% 70%
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Choopanya K, et al. IAS 2013. Abstract WELBC05.
100
80
60
40
20
0
Un
infe
cted
Pts
(%
)
mITT > 67% > 75% > 90% > 95% > 97.5%
Adherence
Patients Uninfected By Level of Adherence
4954
58
6872
84
Bangkok TDF Study: Adherence to PrEP and Risk of HIV Acquisition
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Cautionary Notes from the Bangkok Tenofovir Study
No difference in benefit until AFTER 36 months of treatment
Experienced improved adherence if they received TDF as DOT (89% of the time)
Mostly polysubstance users (ATS ~33%; BZO ~25%)
Only 21% were on MMT
Independent correlates of HIV transmission
– Sharing needles (NSEP was NOT provided as SoC)
– Incarceration (still much structural intervention required)
– Age 20-29 (young injectors remain challenging to engage and involved 43% of the sample)
Choopanya K, et al. Lancet. 2013;381:2083-2090.
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Nanosuspensions: drug nanocrystals suspended in liquid
– Increased drug dissolution rate
– Nanocrystal design allows for low injection volume
Potential utility as long-acting injections for ART regimens, PrEP
– GSK1265744 (DTG analogue) dosed monthly or every 90 days
– TMC278 nanosuspension of RPV dosed monthly
Spreen W, et al. IAS 2013. Abstract WEAB0103.
Long-Acting GSK1265744 and TMC278
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Sustained Released Pharmacotherapies
• Emerging sustained activity for treatment of substance use disorders• XR-NTX• XR-BPN• Implantable NTX and BPN
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Special Concerns for HCV
● Serious problems with the HCV continuum of care
- Diagnosis, linkage & retention, adherence
● Treatment duration
- Lifetime vs 8-12 weeks
● Risk for reinfection: injection network size and $
- Inadequate scale-to-need for harm reduction
● Immediate and lifetime COSTS of treatment
● Shifting treatment to LMICs for PWIDs
- Not the 3x5 mandate witnessed for Africa
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Policy -HIV testing guidelines -HIV treatment guidelines -Siloed funding sources
-Treatment funding - Prevention
-Coordination
-Quality indicators -Service
coordin. -Reim- bursement
-Workforce - Incarceration
Eco-Social Model: Need to Address ALL Key Issues
Community -Stigma -Poverty -Social norms -Neighborhood -Employment -Corrections
Health System -Organization -ASOs/CBOs -Clinic proximity -Clinic culture -Appointments -Supportive svcs -Integrated svcs
-Sex Partners -Family -Friends -Social Networks -Med Providers -Case Managers Communication Factors -Trust -Communication -Longevity -Concordance
Relationships
Individual
Predisposing
-Age-Race/ethnicity-Sex-Sexuality-Mental health-Substance use
Enabling
-Insurance-Housing-Transport-Income-Social support-Food security-CJ status
Need
-Severity-Comorbidities-Health beliefs-Past experiences
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"Half of everything we teach you is wrong... unfortunately, we don't
know which half."