Washington D.C., USA, 22-27 July 2012 Summary of Track C: Epidemiology and Prevention Science Audrey...

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Summary of Track C: Epidemiology and

Prevention Science

Audrey Pettifor, UNC

Christopher Hurt, UNC

Sheri Lippman, CAPS/UCSF

Albert Liu, SFDPH

Sinead Delany-Moretlwe, WRHI

Nora Rosenberg, UNC


The Track C Team


Key Themes and Overview

• We have effective tools• Given limited resources, how do we deliver

interventions to maximize efficiency and effectiveness so we can “Get to Zero”.– Who to target?

• Don’t know how interventions work in some populations (IDU)

– What intervention(s) to use? What combination?– How to deliver to achieve maximum coverage

and impact?


WHO TO TARGET?

Washington D.C., USA, 22-27 July 2012www.aids2012.org (Prejean et al., 2011)

MSM

Most people living with HIV will live where the wealth is concentrated

Source: McKinsey Institute, UNAIDS 2012

2 of every 3 people living with HIV will be living in urban areas by 2030

600 big cities in the world in 2025:

25% of the population 60% of the global wealth

Schwartlander.


Populations at high risk within generalized epidemics

• MSM• IDU• Sex Workers• Adolescents• Aging Populations• Transgender Persons• Discordant Couples


4.8 million young people aged 15 – 24 years are living with HIV.

3 million (two out of every three) are girls

Note: Global summary in title from UNAIDS, Together We Will End AIDS, 2012


Map of HIV prevalence among female sex workers in low-income and middle-

income countries, 2007-2011

• Pooled Odds Ratio for HIV infection among female sex workers compared to other women of reproductive age– 13.5 (95% CI 10.0-18.1)

Baral/Kerrigan et al.THAC0501


New cross-sectional measures of incidence

> 200 cells / ul

< 1.0 OD-n

> 400 copies / ml

< 80%

Classified as recently infected

CD4 cell count

BED CEIA

Avidity

HIV viral load

≤ 200 cells / ul

≥ 1.0 OD-n

≥ 80%

≤ 400 copies/ ml

Stop

Stop

Stop

Stop

•Development of assays (antibody and molecular or “HIV diversity assays”)

•Statistical modeling approaches

•Hybrids (lab + modeling)

•Incidence estimates obtained using the multi-assay algorithm

O. Laeyendecker MOAC0203


What is the right intervention(s) to use for the population(s) targeted and how do we

achieve maximal impact?


Behavioural Intervention

HIV Counselling and Testing

Coates T, Lancet 2000

Male & female condoms

Treatment of STIs

Grosskurth H, Lancet 2000

Male circumcision

Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007

HIVPREVENTION

combined interventions

PMTCT

Harm Reducation/Needl

e exchange

Structural /Social


The effects of MC are sustained

Time-varying Circumcision status

Conventional Cox Model

Unadjusted

Conventional Cox Model

Adjusted for Time-Varying Factors

Cox Regression with Weights from

Marginal Structural Modeling

Circumcised (vs. uncircumcised)

0.38 [0.26 – 0.55]

p<0.001

0.46 [0.31 – 0.69]

p=0.001

0.35 [0.24 – 0.51]

p<0.001

• The protective effect of MMC was sustained at 65% 66 months post intervention

Bailey R. TUAC0402


Option B+ Benefits

Source: UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012


Harm reduction

• Harm reduction is working. In Amsterdam unsafe injections down and incidence declining(Grady MOAC0401)

• In Vietnam, IDUs account for 75% of all new infections. RCT of sexual risk reduction and needle-sharing intervention, needle sharing decreased from 14% at baseline to 3% at 3 months, and exhibited a durable effect (Go THAC0404).

• Modeling results of combination IDU interventions in particular high coverage sterile syringe distribution (Marshall FRLBC05)


Treatment as Prevention

• Mathematical models can help guide decision-making (Granich, Kessler, Stover, Gweshe).

• Targeting all HIV-infected persons is always the most effective strategy

• The challenge will be determining which populations to target in the short-term given limited resources: – What CD4 level? (200-350? 350-500? >500?)– Which patients? (pregnant women? discordant couples? TB

patients? IDUs? all?)

• This will depend on the epidemic context, current service delivery environment , and resources available.

HIV and STI Department, Health Protection Agency - Colindale

HIV and AIDS Reporting System

Why is HIV transmission continuing?

2006 2007 2008 2009 2010.000

5000.00010000.00015000.00020000.00025000.00030000.00035000.00040000.00045000.000 Undiagnosed

Diagnosed and untreatedDiagnosed and treated

Num

ber

livin

g w

ith H

IV

Treated5%

Untreated >50016%

Untreated 350-50012%

Untreated <3505%

Undiagnosed62%

And…

And…in 2010 only 15-25% of MSM had an HIV test

A Brown. THAC0201


Expanding Testing• Home based testing works (Carballo-Dieguez

TUPDC0304)• In South Africa by June 2011 a record

13,269,746 HIV tests were conducted. 16% tested positive of whom 48% had CD4 counts above 350 (Mbengashe THPDE0304)

• Peer testing of IDU in Thailand (Ti THAC0405)


The treatment cascade: keeping people in care

• Success in finding those lost to care in NYC using programs to trace patients out of care (Udeagu MOPDC0306)

• Programs with tracing had lower LTFU, mortality and higher retention (McMahan MOAC0302)

• Community distribution of ART in Tanzania, Uganda and Zambia reduced LTFU (Koole MOAC0305)


PrEP (like ART) works when taken

% of blood samples with tenofovir

detected

HIV protection efficacy in

randomized comparison

Partners PrEPFTC/TDF arm 81% 75%

TDF2 79% 62%

iPrEx 51% 44%

FEM-PrEP 26% 6%

There is a clear dose-response between evidence of PrEP use & efficacy

Baeten et al N Engl Med 2012Grant et al N Engl J Med 2010Van Damme et al N Engl J Med 2012Thigpen et al N Engl J Med 2012Mugo TUPL0102


Why do we need PrEP demonstration projects?

• Will MSM want PrEP?

• How will MSM use PrEP?

• How will sexual practices change?

• Where are PrEP delivery systems best located?

• Will PrEP be safe in the “real world”?

Cohen AIDS 2012


PrEP knowledge, acceptability, and potential for risk compensation

Author/Population Year PrEP Knowledge

PrEP Acceptability

Risk compensation?

Metsch et al653 MSM in Miami, DC

2011 15% Miami30% DC

48% Miami61% DC

--

Duffus et al89 seronegative partners in SD couple in South Carolina(74% heterosexual)

2010-2011

-- 94% 26% would be more likely to have unprotected sex with HIV+ partner, 27% reported would be difficult to take a daily pill

Krakower et al.Internet-based survey of 5035 MSM in North America

Dec 2010-Jan 2011

19% 50% A substantial minority of MSM anticipate risk compensation for insertive (20%) or receptive (14%) anal sex while using PrEP

Yang et al238 MSM and TG men in Northern Thailand

2012 66% 41% for MSM37% for TGs

--

The HIV Investment Framework

Reduce Risk

Reduce likelihood

of transmissio

n

Reduce mortality

and morbidity

Condoms Male

circumcision PMTCT Treatment Key populations Behavior change

BASIC PROGRAMM

E ACTIVITIES

CRITICAL ENABLERS

SYNERGIESAdapted from: Schwartlander B, et al. The Lancet, 377 (9782), 2011

Diagnosed HIV+OR, 3.00 (2.06-4.40)

Undiagnosed HIVOR, 6.38 (4.33-9.39)

Health insurancecoverage

OR,0.47 (0.29-0.77)

>200 CD4 cells/mm3 before

ART initiation OR, 0.40 (0.26-0.62)

ART adherenceOR, 0.50 (0.33-0.76)

HIV suppressionOR, 0.51 (0.31-0.83)

ART utilization/ accessOR, 0.56 (0.41-0.76)

HIV Detection

Viral Suppression

Healthcare visits

OR, 0.61 (0.42-0.90)

Lower income (<$20k)

OR, 3.42 (1.94-6.01)

(Millett, 2012)

STRUCTURAL FACTORS AFFECT RETENTION IN CARE

healthy carer AIDS-affected, abused

AIDS-affected, hungry

hungry, abused AIDS-affected, abused, hungry

0

5

10

15

20

25

30

2.1

6.67.7

10.6

20

% children 14-17 reporting transactional sex

boysgirls

Cumulative impacts of parental HIV/AIDS, abuse and hunger on child transactional sex

Cluver. WEAC0102

Modeling Community Empowerment Interventions on

Infections averted in FSW

• Combined ART and empowerment intervention may avert 16 - 40% of infections among sex workers across epidemics, assuming equal access to HIV testing and treatment

• Empowerment intervention could enable ART access among sex workers through a community-based outreach and mobilization approach

Brazil Kenya Thailand Ukraine0

4,000

8,000

12,000

16,000

20,000

Female sex workers Adults

Cumulative infections averted among FSWs and adults with scale-up of empowerment (2012-16)

A. WirtzTHAC0502

Behavioural Intervention

HIV Counselling and Testing

Coates T, Lancet 2000

STRUCTURAL

Male & female condoms

Treatment of STIs

Grosskurth H, Lancet 2000

Male circumcision

Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007

Treatment for preventionDonnell D, Lancet 2010Cohen M, NEJM 2011

Microbicidesfor women

Abdool Karim Q, Science 2010

Grant R, NEJM 2010 (MSM)Baeten J , NEJM 2012 (couples)Thigpen, NEJM, 2012 (Heterosexuals)

Oral pre-exposure prophylaxis

Post Exposure prophylaxis (PEP)

Scheckter M, 2002

HIVPREVENTION

combined interventions

Mugo TUPL0102

PMTCT

Harm Reduction/Needle

exchange

Washington D.C., USA, 22-27 July 2012 Summary of Track C: Epidemiology and Prevention Science Audrey...

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