slide 1 of 42 ias–usa treatment as prevention: evaluating the impact of haart expansion the...
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Slide 1 of 42
IAS–USA
Treatment as Prevention:Evaluating the Impact of HAART Expansion
The British Columbia (BC) Experience
AU EDITED FINAL: 03-18-13
Julio Montaner, MDProfessor of Medicine, and Head, Div. of AIDS, University of British Columbia
Director, BC-Centre for Excellence in HIV/AIDS at Providence Health CarePast President, International AIDS Society (2008-2010)
Slide 2 of 44
January 2004
Summer of 1996
Year
Summer of 2000
Phase I Phase II Phase III
Montaner et al, Lancet, 2010
Increasing HAART Coverage within Evolving Guidelines in BC
N = 7492 by the end of 2011
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BC: All Cause Mortality (#)
0
50
100
150
200
250
300
350
400
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Years
Freq
uenc
y
> 90% Decrease in All Cause Mortality among HIV Infected Individuals in BC since 1996
Montaner et al, TasP Workshop, April 2012
Slide 5 of 44HAART Use & New HIV Diagnoses for BC by year, 1996-2012
Lima et al, in preparation, 2013
HIV Incidence
Active on HAART
New HIV Diagnoses (All)
New HIV Diagnoses (Ever IDU)
Slide 10 of 44Engagement in the Cascade of Care in BCNosyk et al, in preparation, 2012
Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009
Supp rate: 35% [30% - 40%] for pVL ≤40c/mL x2. Supp rate: 51 & 60% for a single pVL<50 or <500c/mL, respectively.
Engagement in the Cascade of Care in BCNosyk et al, TasP Workshop, 2013Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009
We used pVL ≤40c/mL x2, thus overall supp rate is: 35% [30% - 40%].
This becomes 51% & 60% if a single pVL<50 or <500c/mL are used.
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Programmatic Compliance Score Assesses the impact of non-
compliance with HIV treatment guidelines on all-cause mortality
PCS components include: Baseline CD4 > 200/mm3 Three CD4 in 1st year Three VL in 1st year Baseline resistance Recommended HAART Undetectable pVL at 9 months
Failure to meet a given component add one to the score
PCS predicts mortality
Lima et al. PLoS ONE 7(11): e47859. 2012
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TasP Monitoring in the Real World
• In a perfect world, all HIV infected individuals would follow the same pathway in the spectrum of engagement into care:
• In the real world, there is attrition between each of these steps and individuals are often lost-to-follow-up.
• Understanding the attrition points (leakage), and their causes are essential to optimize the effectiveness of TasP.
• This can only be achieved by comprehensively monitoring standardized metrics, on a longitudinal basis and accounting for multiple sources of bias and heterogeneity (i.e.: geographic, socio-demographic, risk factors, etc).
HIV
InfectedHIV
Diagnosed
Linked to HIV Care
Retained in HIV
Care
Need ART
On ART
Adherent/Suppressed