HIV in Japan

24 April 2018

Emeritus Professor, University of TokyoManaging Director, Japan Agency for Medical Research and Development

Aikichi Iwamoto, M.D.

IAS-JCIE Symposium

1

AIDS and HIV-1

Slim’s disease Pneumocystis pneumonia

1981

1983

・1981 First case report of AIDS from Los Angeles・1983 Discovery of HIV-1 by Franҫoise Barre-Sinoussi

Brief history of HIV/AIDS

HIV infection

Acute infection Asymptomatic phase AIDS

AIDS is the terminal phase of HIV infection

3

1996～

Improvement of prognosis by antiretroviral therapy

AIDS: Disease caused by CD4 depletion caused by HIV

9 leading causes of death, U.S.A. in 1987-2006Male 25-44 y/o

4

5

Denmark Cohort. Lohse N et al. Ann Intern Med 2007;146:87-95.

1997-1999 2000-2005

7.6

22.5

32.5

37.8

51.1

0

10

20

30

40

50

60

total HCV(-)

Age

33

48

5863

76

General populationBefore 1995

Further improvement of antiretroviral drugs and prognosis

Estimated life expectancy of the people infected by HIV at 25

One HIV-1-positive, the other negative

Immediate ARTCD4 350-550

Delayed ARTCD4 <250

1,763 randomized couples

886 877

Cohen, MS et al., N Engl J Med 375:9, 2016.

・ Early ART was associated with a 93% lower risk of linked partner infection・ No linked infections when HIV-1 infection was stably suppressed by ART.

Treatment as Prevention

Recent breakthrough-1

Partnerinfection

Lundgren JD et al, NEJM 373:795-807, 2015.

4,685 patients：CD4 651 /μL (median)

Immediate ART Deferred ART CD4<350

Benefits of the initiation of ART with CD4 > 500

Recent breakthrough-2

Deferred

Immediate

0

200

400

600

800

1000

1200

85 87 89 91 93 95 97 99 1 3 5 7 9 11 13 15

8

(Japanese ＋ Foreign)

(Male ＋ Female)

2017HIV: 992AIDS： 415（Preliminary）

Annual new report of HIV／AIDS in Japan

（New report / year）

AIDS case reporting in Japan： AIDS cases at HIV diagnosis

Indicates the late presenters and does not reflect the improvement of ART.

HIV

AIDS

Percent on ART at IMSUT Hospital

0

10

20

30

40

50

60

70

80

90

100

0

200

400

600

800

1000

1200

85 87 89 91 93 95 97 99 1 3 5 7 9 11 13 15

% on ART HIV

Reported cases on ART

0

10

20

30

40

50

60

70

80

90

100

HIV care cascade study in U.S.A.

Infected Diagnosed Linked to care

Retainedin care

Viralsuppression

PrescribedART

1,106,400

874,056

655,542

437,028

262,217209,773

Gardner, EM et al. CID 52: 793-800, 2011

79%

59%

40%

24%19%

100%

Denominator: Estimated number of infected people

11Gardner, EM et al. CID 52: 793-800, 2011

HIV care cascade study in U.S.A.: Implications for countermeasure

Minimal improvement by 90% accomplishment of individual stepsEnormous improvement of treatment success by the 90 % accomplishment of all rates of diagnosis, treatment and undetectable viral load.

HIV cascade in Japan: Methods

(1) Undiagnosed HIV-positive people・ Average HIV-positive numbers who donated blood for the first time in 2011-2015 to Japanese Red Cross.

・ Extrapolation using the age- and sex-matched overall population on October 2015.

(2) Diagnosed HIV-positives・ Cumulative data from the Annual AIDS Surveillance Report.

・ Included the number from the Nationwide Survey on Coagulation disorders

・ Subtracted the number of foreigners who left Japan based on an estimation reported previously.

・ Subtracted the number of reported AIDS-related deaths.

(3) Nationwide questionnaire survey of the AIDS core hospitals・ Health and Labour Sciences Research Grants to Y. Yokomaku.

100

8677

71 70

0

10

20

30

40

50

60

70

80

90

100

Estimated

patients

Diagnosed Retained in care on treatmen Undetectable VL

86% 83% 99%

HIV care cascade and 90-90-90 in Japan

Iwamoto A et al, The HIV care cascade: Japanese perspectives. PLOS ONE. March 20, 2017.

More than 2,000 more people are attending the hospitals without reply or private clinics and are on treatment with suppressed viral load.

0

200

400

600

800

1000

1200

85 87 89 91 93 95 97 99 1 3 5 7 9 11 13 15

14

(Japanese nationality：Male + female)

HIV in Japan: What’s next?

（new report / y）

HIV

AIDS

1. Testing promotion?

2. Decreasing new infection?

3. Decreasing new AIDS?

Testing at health centers, positive numbers

& positive rate

0

100

200

300

400

500

600

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

検査件数(保健所等) 陽性数(実数） 陽性率(100,000検査当)

15

Strategic research

Further promotion of current testing would not be effective

Summary

16

Yes

Yes

・ Revolutionary improvement of ART

・ Treatment as Prevention

・ Is AIDS over in Japan? No!

・ Time for integrated treatment and prevention

・ Personal opinion for the next:More research on those who do not test and get AIDS.