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HIV Testing and Treatment:
The Magnitude of the Impact
Rochelle P. Walensky, MD, MPH
Associate Professor of Medicine
Harvard Medical School
Division of Infectious Diseases
Massachusetts General Hospital
Brigham and Women’s Hospital
Supported by NIAID, NIMH, and CDC
Overview
1)
2)
3)
4)
5)
Treatment successes in HIV/AIDS
New WHO HIV treatment guidelines
When to initiate antiretroviral therapy
HIV screening
Impact of alternative PEPfAR scale-up
strategies
6) PEPfAR in the context of maternal/child
health
HIV Treatment is Very Effective:
Per Person Survival Gains (months)
Survival Gains for Disease Interventions
160
160
140
120
92
100
80
60
50
40
20
29
7
0
Chemotherapy
Adjuvant
chemotherapy
Acute MI
BMT
ART
Lung cancer
Breast cancer
Coronary artery
disease
Relapsed nonHodgkins
lymphoma
AIDS
Walensky et al. JID, 2006
November 2009
The proposed changes
1) Replacement of stavudine with
tenofovir
2) Increased number of sequential ART
regimens
3) Earlier ART initiation at CD4 <350/µl
instead of <200/µl
“When to Start” Strategies
Impact over the next 5 years
(South Africa)
Strategy
ART at CD4 <350/μl
Total OIs
730,272
Total Deaths
244,249
ART at CD4 <250/μl
951,370
497,059
(221,097)
(252,810)
Difference (<350 - <250/μl)
OI: opportunistic infection
( ): denotes fewer ODs and deaths with ART at <350/μl
Walensky et al. Ann Int Med, 2009
When is Antiretroviral Therapy Started?
• Review of data from 2003-2005 from 42 countries, 176 sites,
n=33,008
• Since 2000, CD4 at initiation in developed countries stable at
about 175 cells/µl, increasing in Sub-Saharan Africa from 50 
100 cells/µl.
Egger M, 14th CROI, Los Angeles 2007, #62.
When is Antiretroviral Therapy Started?
• Review of data from 2003-2005 from 42 countries, 176 sites,
n=33,008
• Since 2000, CD4 at initiation in developed countries stable at
about 175 cells/µl, increasing in Sub-Saharan Africa from 50 
100 cells/µl.
Egger M, 14th CROI, Los Angeles 2007, #62.
Percent HIV-infected adults who
were tested and received result
Country
Overall
Dominican Republic
Swaziland
Rwanda
Haiti
60.7
38.7
31.4
24.5
Zimbabwe
Côte d’Ivoire
India
23.7
16.5
10.8
Democratic Republic of Congo
Ethiopia
10.5
7.6
WHO: http://who.int/hiv/pub/towards_universal_access_report_2008.pdf
HIV Screening 2 Outpatient Depts:
Durban, South Africa 2008
HIV Testing
2,775
No test/result: 71
Indeterminate: 6
HIV-negative
1,308
Bassett et al. AIDS 2010
HIV-infected
1,467
54% HIV
prevalence
How many start ART?
2,775
HIV Tested
HIV-infected
1,467
CD4/results
Eligible for ART
Start ART
605
Failure to
obtain CD4
368
154 (42%)
Failure to
start ART
when eligible
Median time to
ART initiation:
100 days
Bassett et al. AIDS 2010
High Rate of Mortality
15% of HIV-infected cohort
Bassett et al. AIDS 2010
High Rate of Mortality
15% of HIV-infected cohort
ART Roll Out in South Africa:
The impact of speed on survival
To examine alternative ART rollout
scenarios in South Africa and to forecast
number of lives lost while awaiting
therapy
Walensky et al JID 2008
4 Growth Scenarios
New ART Slots
by 2012
Source
Zero growth
100,000
---
Constant growth
600,000
ASSA
Moderate growth
2,100,000
SA Joint Task Team
Rapid growth
2,400,000
---
Walensky et al JID 2008
Projected Deaths & Alive on ART:
South Africa, 2007-2012
AIDS Deaths
Alive on ART
Zero growth
2,465,000
1,290,000
Constant growth
2,160,000
1,595,000
Moderate growth
1,449,000
2,306,000
Rapid growth
1,232,000
2,523,000
Walensky et al JID 2008
Projected Deaths and
Patients Alive on ART: 2007-2012
AIDS Deaths
Alive on ART
Zero growth
2,465,000
1,290,000
Constant growth
2,160,000
1,595,000
Moderate growth
1,449,000
2,306,000
Rapid growth
1,232,000
2,523,000
Walensky et al JID 2008
Are HIV Testing &Treatment CostEffective in These Settings?
• Routine HIV screening (South Africa)
YES: $1,940/YLS for annual screening compared to
screening every 5 years (Walensky, CROI 2009)
• ART in resource-limited settings (Côte d’Ivoire)
YES: $590/YLS compared to no ART (Goldie, NEJM 2006)
• ART initiation at CD4 <350/µl (South Africa)
YES: $1,200/YLS ART at ≤350 cells/µl vs ART at CD4 ≤250
cells/µl (Walensky Ann Intern Med 2009)
PEPfAR & Maternal/Child Health
• HIV testing, access to care, treatment and
maternal/child health are linked at the core
• Allows for prevention of mother to child
HIV transmission
• Allows for safe breastfeeding in lieu of
formula feeding with potentially
contaminated water
• Prevents orphan-associated mortality
– 10X increase risk of death
% pregnant women receiving an HIV test
PEPfAR & Maternal/Child Health
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
95% 95%
2004
2005
2006
2007
76%
66%
48%
40%
40%
52%
8%
Europe and
Central Asia
Latin America
and the
Caribbean
18%
13%
10%
4% 3% 7% 8%
Sub-Saharan
East, South
Africa
and South-East
Asia
WHO: http://who.int/hiv/pub/towards_universal_access_report_2008.pdf
Conclusions
1. Life saving benefits of ART in HIV disease are
greater than for virtually any other adult
disease
2. Globally, these benefits can be increased by:
a. Increasing HIV testing and diagnosis
b. Increasing access to earlier ART
c. Making better drugs available
3. HIV testing and treatment are very costeffective
4. HIV testing and treatment form the foundation
for maternal/child health in areas of high HIV
prevalence
Results:
Percent ART Need Met by Year
Rapid
100%
% ART Need Met
90%
80%
Moderate
70%
60%
Constant
50%
40%
Zero
30%
20%
10%
0%
2007
2008
2009
2010
Year
Walensky et al. JID 2008
2011
2012
Proportion Alive
Proportion Alive at 5 Years
1
Earlier ART
0.9
Deferred ART
0.8
0.7
No treatment
0.6
0.5
0
1
2
3
4
5
Time (Years)
Walensky et al. Ann Int Med 2009
AIDS Survival by Era
100%
Untreated HIV/AIDS
% Alive
90%
1989 - PCP
80%
1993 - PCP/MAC
70%
1996 - PCP/MAC + ART 1
1998 - PCP/MAC + ART 2
60%
2000 - PCP/MAC + ART 3
50%
2003 - PCP/MAC + ART 4
40%
30%
20%
10%
0%
0
5
10
15
20
25
30
Years from treatment start
35
40
“When to Start” Strategies
Impact over the next 5 years
(South Africa)
Discounted
Total Deaths Total Costs ($)
244,249
12,054,287,800
Strategy
ART at CD4
<350/μl or OI
Total OIs
730,272
ART at CD4
<250/μl or OI
951,370
497,059
10,634,516,900
(221,097)
(252,810)
1,419,770,900
Difference
(<350 - <250/μl)
OI: opportunistic infection
( ): denotes fewer ODs and deaths with ART at <350/μl
CD4 count within 90 days
HIV-infected
1,467
Yes
607
CD4<200/μl
368
Bassett et al. AIDS 2010
No
862
CD4≥200/μl
237
59% no CD4
within 90 days
61% CD4<200/µl
ART eligible
at baseline