Quiz

Global Control of HIV/AIDS: Are We Winning the War On AIDS?

Thomas C. Quinn, MD Johns Hopkins University

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Current Status

Section A

! 76 million total HIV infections

! 39 million total AIDS deaths

! 37 million people living with HIV

! 16 million people accessing treatment

! 1.2 million AIDS deaths

! 2.0 million new HIV infections

Current Status of the Global HIV/AIDS Pandemic

3

Global Prevalence of HIV Infection—Incidence: 37 Million; New Infections: 2.0 Million; AIDS Deaths: 1.2 Million

4

The HIV burden in sub-Saharan Africa: — 25 million living with HIV — 1.4 million new infections — 0.8 million deaths

Top 10 Countries, Adult HIV Prevalence

5

Newly Diagnosed HIV Infections in the European Region, 2004– 2013

6

! An expanding HIV epidemic, largely driven by unsafe injection drug use; heterosexual transmission now also a major component of epidemic growth

! Access to antiretroviral treatment remains low, particularly for key affected populations

HIV in Eastern Europe and Central Asia

7

! An expanding HIV epidemic, largely driven by unsafe injection drug use; heterosexual transmission now also a major component of epidemic growth

! Access to antiretroviral treatment remains low, particularly for key affected populations

! HIV prevention is not accessible at sufficient scale; access to harm reduction remains very limited

! High levels of stigma and discrimination; numerous structural, cultural, societal and political obstacles to the AIDS response

! Low levels of cooperation between government and the non-governmental sector

HIV in Eastern Europe and Central Asia

8

Cumulative HIV Cases and Deaths among PLHIV in the Russian Federation, 1987–2013

9

! People who inject drugs (PWID)

! Sexual partners of PWID

! Men who have sex with men (MSM)

! Sex workers

! Incarcerated people

! Migrants and their sexual partners

! Concentrated epidemics now co-existing with an independent heterosexual epidemic unlinked to these risk groups

Key Population at High Risk in Eastern Europe and Central Asia

10

Elevated Incidence among Key Populations in Concentrated Epidemics

11

HIV/AIDS in the United States

12

! 1.2 million people living with HIV infection, of whom 14% are unaware of their infection

! 648,000 people have died of AIDS

! Approximately 50,000 new infections per year for the past two decades

! MSM, Blacks/African Americans face the most severe burden of HIV

! Youths aged 13–24 years account for more than 25% of new infections

HIV in the United States

13

Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, 2010–2014 (US and Six Dependent Areas)

Source: CDC. 14

Rates of Diagnoses of HIV Infection among Adults and Adolescents, by Age at Diagnosis, 2010–2014

Note: Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. 15

Diagnoses of HIV Infection among Adults and Adolescents, by Sex and Transmission Category, 2014 (US and Six Dependent Areas)

Source: CDC. 16

So Why Is Everyone Talking about an AIDS-Free Generation?

17

So Why Is Everyone Talking about an AIDS-Free Generation?

18

FDA-Approved Antiretroviral Drugs

19

Antiretroviral Therapy Helps People with HIV Live Longer

Sources: CDC Fact Sheet, 11/2014; National Vital Statistics Reports. (2012). PLoS One. (2013); JAMA. (1993). 20

Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House. 21

! “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination”

Vision for the National HIV/AIDS Strategy

22Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Strategy goals

National HIV/AIDS Strategy

23Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Strategy goals ! Reduce new infections

National HIV/AIDS Strategy

24Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Strategy goals ! Reduce new infections ! Increase access to care and improve health outcomes for people living with HIV

National HIV/AIDS Strategy

25Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Strategy goals ! Reduce new infections ! Increase access to care and improve health outcomes for people living with HIV ! Reduce HIV-related health disparities and health inequities

National HIV/AIDS Strategy

26Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Strategy goals ! Reduce new infections ! Increase access to care and improve health outcomes for people living with HIV ! Reduce HIV-related health disparities and health inequities ! Achieve a more coordinated national response to the HIV epidemic

National HIV/AIDS Strategy

27Source: National HIV/AIDS Strategy for the United States: Updated to 2020. (2015, July). The White House.

! Increase the percentage of people living with HIV who know their serostatus to 90%

! Reduce the number of new diagnoses by at least 25 percent

! Reduce the percentage of young gay and bisexual men who have engaged in HIV-risk behaviors by at least 10%

! Increase the percentage of newly diagnosed persons linked to HIV medical care within one month of their HIV diagnosis to at least 85%

! Increase the percentage of persons with diagnosed HIV infection who are retained in HIV medical care to 90%

! Increase the percentage of persons with diagnosed HIV infection who are virally suppressed to at least 80%

Indicators of Progress: 2020

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! Reduce the percentage of persons in HIV medical care who are homeless to no more than 5%

! Reduce the death rate among persons with diagnosed HIV infection by at least 33%

! Reduce disparities in the rate of new diagnoses by at least 15% in the following groups: gay and bisexual men, young Black gay and bisexual men, Black females, and persons living in the Southern United States

! Increase the rate of viral suppression in HIV-positive youths and adults who inject drugs to at least 80%

Indicators of Progress: 2020 (cont.)

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! Advances in four key areas are of critical focus for the next five years ! Widespread testing and linkage to care, enabling people living with HIV to access

treatment early ! Broad support for people living with HIV to remain engaged in comprehensive care,

including support for treatment adherence ! Universal viral suppression among people living with HIV ! Full access to comprehensive PrEP services for those for whom it is appropriate and

desired, with support for medication adherence for those using PrEP

HIV Prevention Strategies

30

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International Response

Section B

Year 2000: The International Response

2

3

International Donations Invested in AIDS Programs in Low- and Middle- Income Countries

4

People Receiving Antiretroviral Therapy, All Countries

5

Global Number of People Living with HIV and HIV-Related Deaths: Changes Post-2005

Source: UNAIDS Global Report 2014. 6

Dramatic Impact of PEPFAR on Life Expectancy: Rebound in Countries Significantly Impacted by HIV/AIDS

7

! Fifty percent drop in incidence in 25 countries

UN Announces Major Drop in New HIV Cases

8

Michel Sidibé, UNAIDS Executive Director

9

Five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights

10

! Impact and sustainability agendas: make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment, and care interventions

Five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights

11

! Impact and sustainability agendas: make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment, and care interventions

! Partnership agenda: work with partner countries, donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral institutions to effectively mobilize, coordinate, and efficiently utilize resources to expand high-impact strategies, saving more lives sooner

Five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights

12

! Impact and sustainability agendas: make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment, and care interventions

! Partnership agenda: work with partner countries, donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral institutions to effectively mobilize, coordinate, and efficiently utilize resources to expand high-impact strategies, saving more lives sooner

! Efficiency agenda: set benchmarks for outcomes and programmatic efficiencies through regularly assessed planning and reporting processes to ensure goals are being met

Five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights

13

! Impact and sustainability agendas: make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment, and care interventions

! Partnership agenda: work with partner countries, donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral institutions to effectively mobilize, coordinate, and efficiently utilize resources to expand high-impact strategies, saving more lives sooner

! Efficiency agenda: set benchmarks for outcomes and programmatic efficiencies through regularly assessed planning and reporting processes to ensure goals are being met

! Human rights agenda: focus on women and girls to increase gender equality in HIV services and end stigma and discrimination against people living with HIV and key populations, improving their access to, and uptake of, comprehensive HIV services

Five Action Agendas—Impact, Efficiency, Sustainability, Partnership, and Human Rights

14

WHO 2015: Updated Treatment Guidelines for Adults, Adolescents, and Children

15

! Expanded ART eligibility

! ART initiation now recommended for all patients, regardless of CD4+ cell count

! Viral load testing preferred for monitoring ART

! Preferred initial regimen: fixed-dose TDF + 3TC (or FTC) + EFV ! Discontinue use of d4T due to toxicity

WHO 2015: Updated Treatment Guidelines for Adults, Adolescents, and Children

16

2015 Update: EACS Guidelines for Treatment of HIV-Infected Patients

! ART initiation now recommended for all patients, regardless of CD4+ cell count

Guideline AIDS or HIV-related

symptoms

CD4+ cell count (cells/mm3)

<350

CD4+ cell count (cells/mm3)

350–500

CD4+ cell count (cells/mm3)

>500

EACS[1] Yes Yes Yes Yes

DHHS[2] Yes Yes Yes Yes

IAS-USA[3] Yes Yes Yes Yes

WHO[4] Yes Yes Yes Yes

[1] EACS HIV Guidelines. V 8.0. (2015, October). [2] DHHS Guidelines. (2015, April). [3] Günthard, H., et al. (2014). JAMA, 312, 410–425. [4] WHO. (2015, September). When to Start Guidelines. 17

Antiretroviral Therapy Coverage for Adults and Children

18

UNAIDS 90-90-90: HIV Treatment Targets for 2020 with Global Estimates

19

Global Estimates (2014–2015) vs. the Gap to Reach 90-90-90 Targets

20

Cascade of HIV Care—Russia 2014

21

Cascade of HIV Care—Sub-Saharan Africa 2014

22

Cascade of HIV Care—United States 2013

23

Target 3: Percentage of HIV+ People with HIV RNA Suppression—Results

24

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Prevention

Section C

Global Number of New HIV Infections in Adults and Children: 1990–2013

Source: UNAIDS Global Report 2014. 2

Prevention Tools Showing Efficacy in Recent Randomized, Controlled Clinical Trials

3

! 1.1% (0.8%–1.4%) reduction in HIV incidence for each 1.0% increase in treatment coverage

A Clear Correlation Exists between HIV Treatment and Incidence

4Source: Tanser et al. (2013). Science, 339, 966–971.

The Tipping Point: Understanding a Crucial Milestone in the AIDS Response

5

HIV Incidence vs. ART Coverage in 51 Countries, Weighted by Epidemic Size

Source: Hill, Pozniak, Raymond, Heath, and Ford. (2014). AIDS 2014. 6

AIDS-Free Generation = Prevention of Mother-to-Child Transmission of HIV

7

Global Plan for the Elimination of New HIV Infections in Children by 2016

8

50% reduction between 2014 & 2015 Only slightly off track for target

! Zero new HIV infections

! Zero discrimination

! Zero AIDS-related deaths

Vision

9

HIV Sexual Transmission

10

Four Prevention Opportunities

Sources: Cohen et al. JCI 2008; Cohen. IAS 2008. 11

Medical Male Circumcision

12

Adult Male Circumcision Provides Long-Lasting Protection against HIV Infection in Rakai, Uganda

13

! Male circumcision should now be recognized as an additional, important intervention to reduce the risk of heterosexually acquired HIV infection in men

! Male circumcision should be part of a comprehensive HIV prevention package

! Adequate training, hygiene, monitoring, and counseling are critical

! Modeling studies suggest that male circumcision is sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years

WHO and UNAIDS Announce Recommendations from Expert Consultation on Male Circumcision for HIV Prevention

14Source: UNAIDS. (2007, March 28).

Medical Male Circumcision: Research to Policy

15

! Prevention of mother-to-child transmission

! Post-exposure prophylaxis

! Pre-exposure prophylaxis

! Treatment of chronic infection

Antiretroviral Therapy as HIV Prevention

16

Study Population N Efficacy

CAPRISA 004 South Africa

Women 889 39% TFV gel

iPrEx Brazil, Ecuador, Peru,

South Africa, Thailand, US MSM 2499 44% FTC/TDF

TDF2 Study Botswana

Young men and women 1219 62% FTC/TDF

Partners PrEP Study Kenya, Uganda

Heterosexual couples 4758 67% TFV 75% FTC/TDF

Bangkok Tenofovir Study Thailand

IDUs 2413 49% TFV

Successful PrEP Efficacy Trials

17 Sources: Grant, R. M., et al. (2010). N Engl J Med, 363, 2587-2599; Baeten, J. M., et al. (2012). N Engl J Med, 367, 399-410; Thigpen, M. C., et al. (2012). N Engl J Med, 367, 423-434; Choopanya, K., et al. (2013). Lancet, 381, 2083-2090.

Effectiveness and Adherence in Trials of Oral and Topical Tenofovir-Based Prevention

18

HIV Incidence and Drug Concentrations

Sources: Grant. WAC 2014, Melbourne; Grant et al. (Published online July 22, 2014). Lancet Infectious Diseases. 19

Priorities for New Technologies

20

“On Demand” Sustained Release Long-Acting Injectable

• Used around the time of intercourse

• For those who have intermittent sex or want more direct control over their protection

• User-initiated, does not require daily action

• Should increase adherence and effectiveness

• Co-administration of products targeting separate indications

• Equal duration of effectiveness for the co-administered products

! Slow scale-up of proven interventions: PMTCT, circumcision, TasP, PrEP

! Problems in the “care continuum”: access, retention, and adherence to therapy and prevention

Challenges in Controlling the HIV/AIDS Pandemic

21

! Slow scale-up of proven interventions: PMTCT, circumcision, TasP, PrEP

! Problems in the “care continuum”: access, retention, and adherence to therapy and prevention

! Human nature: recidivism in the face of success

! Social and cultural barriers: stigma and legal impediments

Challenges in Controlling the HIV/AIDS Pandemic

22

Cultural Barriers and Stigma Continue to Impede HIV-Prevention Efforts

! Condoms meant for protection used as evidence by police ! Homosexuality illegal in 76 countries

Sources: AS Fauci/NIAID; Human Rights Watch 2012. 23

The Care Continuum and the Prevention Continuum

24

The Care Continuum and the Prevention Continuum

25

“90-90-90” Targets for 2020

Source: UNAIDS. (2014). 26

90% diagnosed 90% on treatment 90% virally suppressed

The Care Continuum and the Prevention Continuum

27

Tailored Prevention Using HIV Prevention Toolkit

28

Future Effects of Combination Prevention in South Africa

Source: Cremin, I., et al. (2013). AIDS. 29

! Global progress on scale-up of ART has been extraordinary, and the target of 20 million can be reached by 2020

Conclusions

30

! Global progress on scale-up of ART has been extraordinary, and the target of 20 million can be reached by 2020

! Further scale-up must address disparities and inequities (countries, key populations)

Conclusions

31

! Global progress on scale-up of ART has been extraordinary, and the target of 20 million can be reached by 2020

! Further scale-up must address disparities and inequities (countries, key populations)

! ARVs for treatment and prevention are a powerful tool towards ending the HIV epidemic, but only if retention in care, adherence to medication, and behavioral change are emphasized

Conclusions

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