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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