HIV TREATMENT AS PREVENTION

THE KEY TO AN AIDS-FREE GENERATION

Adeeba KamarulzamanProfessor of Medicine

University of Malaya

Executive Council Member

International AIDS Society

Since the beginning of the epidemic

70 million

infections

35 million

deaths

1980 1985 1990 1995 2000 2005 2010 2015 2020

1981 AIDS 1983 HIV1983 WHO surveillance1983 Denver Principles

1985 HIV test1987 AZT1987 WHO GPA1987 TASO Uganda1985 Reagan mentions AIDS1986 AIDS Quilt1986 ACT-UP

1992 AIDS #1 killer US men 25-44 years old1993 US Office of National AIDS Policy1994 AZT to prevent MTCT

1995Protease inhibitor1996Vancouver triple therapy1996 US home HIV test1997 AIDS deaths decline 40% in US1998 TAC South Africa

2001

Special UN

Session

“global

emergency”2002

Leading

cause of

death

2002

Global Fund

established

2003

PEPFAR

2003

WHO 3x5

2005 1st

generic ARVs2005 Circumcision RCTs2006 TasPproposed as HIV control strategy2008 Swiss statement2009 AttiametaanalysisART prevents transmission2009 WHO proposes using treatment to eliminate HIV

2011HPTN 052 proves ART blocks transmission2012 PrEPapproved in US2010 UNAIDS Treatment 2.0 with treatment as prevention2014 UNAIDS 90-90-90 targets

2015 Fast Track Cities with 60+ cities2015 STAR and TEMPRANO2015 HealthGapaccess to treatment is human right 2016 18.2 M (49%)people on treatment2016 Cumulative 39 million AIDS deaths

2020 90-90-90 reached

2020 95-95-95 targets affirmed

Devastation Discovery End of AIDS

1980 100,000 PLHIVNo treatment (Tx)

2000 34.3M PLHIV1M (3%) TxAfrica50,000 (2%)

2005 40.3M PLHIV2M (5%) Tx

201033.3M PLHIV7.5M (23%) treatment

2015 36M PLHIV16M (44%) Tx

202037M PLHIV27 (81%) Tx

Hit early, hit hard. Almost no access to

treatment in low and middle income countries2003 WHO

CD4 <200

2009 WHO

CD4 <3502012 US Treat All

2013 WHOCD4 <500

2015 WHO

Irrespective CD4Policy

1985 Nearly million PLHIVNo treatment

1990Millions PLHIVNo treatment

199520M PLHIVNo Tx

Phases of HIV Epidemic 1980-2020

Granich Lancet 2017

Four Prevention Opportunities

YEARS

Treatment Of HIVReduced Infectivity

INFECTED

YEARS

UNEXPOSED

Behavioral,Structural

Harm ReductionCircumcision

Condoms

Cohen et al, JCI, 2008Cohen IAS 2008

HOURS

VaccinesART PrEP

Microbicides

EXPOSED

(precoital/coital)

72h

VaccinesART PEP

EXPOSED

(postcoital)

HIV/AIDS before ART

• Prevents disease

progression

• Restores immune

health

• Early treatment:

–Reduced death

–Reduced cancer

–Reduced tuberculosis

Antiretroviral Therapy works:

Treatment for treatment

Decline in HIV incidence and mortality over time

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

3 500 000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

People dying from AIDS-related causes globally

People newly infected with HIV/AIDS globally

Source: UNAIDS/WHO estimates.

Annual number of new HIV infections

2010-2016

• Eastern and southern Africa (29%)

• Asia and the Pacific (13%)

• Western and central Africa (9%)

• W & Central Europe and N America (9%)

• Eastern Europe and central Asia (60%)

2016

1.8M

new

infections

1M

deaths

36.7M

living with

HIV

5000 new infections per day

• Post-exposure prophylaxis

(PEP)

• Prevention of vertical

transmission (PMTCT)

Antiretroviral Therapy works:

Prevention

TREATMENT IS PREVENTION

The OPPOSITES ATTRACT Study (2017)

U=UUndetectable

Equals Untransmittable

ENDING AIDS TARGET BY 2030UNAIDS new Global Direction

PrEP reduces the risk of getting HIV from sex by more than 90% when used

consistently.

Among people who inject drugs, PrEP reduces the risk of getting HIV by

more than 70% when used consistently.

Number of people living with HIV

on antiretroviral therapy, global, 2010–2015

Sources: Global AIDS Response Progress Reporting (GARPR) 2016; UNAIDS 2016 estimates.

2015 target within the 2011

United Nations Political

Declaration on HIV and

AIDS

Package of Interventions

Outreach

• Identification

• Peer lead

• Information & Education

• Support

Prevention• Information &

education

• Counselling

• Testing

• Condom promotion

• PEP

• PREP• STI screening

• TB screening

Treatment

Test & Treat

ART

Viral loads

Opportunistic infections

STI treatment

Linkage to care (second line)

Support

Adherence

Trauma counselling

Creative spaces

Support groups

Human rights protection

22

90-90-90 and The HIV Care Continuum

Diagnosed

PLHIVDiagnosed

PLHIV on ART

PLHIV on ART

Virally

Suppressed

81% 73% 90%

90% 90% 90%

Diagnosed

PLHIVPLHIV on

ART

PLHIV Virally

Suppressed

90-90-90 Targets

HIV Care Continuum

Program Interventions that

address the HIV care CONTINUUM

HUMAN RIGHTS

Prevent new infections

HIV diagnosis

Link to care

Retain in care

TreatSuppress viral load

Prevent illness

and AIDS deaths

90-90-90 and NHAS targets

:not too ambitious, but a really good start

J Justman, CROI2017

Top 21 countries reporting more than 84% of

people living with diagnosed HIV (2010-2016)

90

% 76 countries with complete care continua

98%

92%91%

90% 90%89%

88% 88%87% 87% 87% 87% 87%

86% 86% 86% 86%85%

84% 84% 84%

75%

80%

85%

90%

95%

100%

Pro

po

rtio

n o

f p

eo

ple

liv

ing

wit

h H

IV

dia

gn

os

ed

Top 21 countries reporting more than 64% of

people living with HIV on ART (2010-2016)

81

% 76 countries with complete care continua

86% 85%83%

77%75% 75% 75% 75% 75% 75% 74%

72% 72% 72% 71% 71% 70% 70%

66%64% 64%

40%

50%

60%

70%

80%

90%

100%

Pro

po

rtio

n o

f p

eo

ple

liv

ing

wit

h H

IV

on

AR

T

Top 20 countries reporting more than 53% of people

living with HIV with viral suppression (2010-2016)

73

% 76 countries with complete care continua

80%78% 78%

72% 72%70% 70%

68% 67% 67% 66%64% 63% 62% 62%

60% 59%57%

54% 53%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

po

rtio

n o

f p

eo

ple

liv

ing

wit

h H

IV

wit

h v

iral

su

pp

ressio

n

• “CAMBODIA IS ON TRACK TO ACHIEVE THE 90-90-90

TARGETS. CAMBODIA’S RESPONSE TO AIDS BEGAN

IN THE EARLY 1990S, WHEN THE COUNTRY FACED A

GENERALIZED, FAST-GROWING EPIDEMIC. TODAY,

WE ARE FOCUSING ON PRIORITY POPULATIONS

AND AIM TO ELIMINATE NEW HIV INFECTIONS BY

2025.”

• MAM BUN HENG MINISTER OF HEALTH, CAMBODIA

HIV & AIDS Epidemic in MalaysiaComparison of New HIV Infections between Injecting Drug Users (IDU)

& Sexual Transmission (2005-2016)

Source: HIV/STI Sector, Division of Disease Control, Ministry of Health Malaysia

ILZ

SAHABAT

DIC Pahang

FHDA PG & KD

WAKE

ILZ

Global Fund Funded Projects (2016 – 2018):

16 Projects, 52 Government Clinics - PWID, SW & MSM

Program.

Insaf Murni

PAMT KL & N9

PWID

SW

34

KLASS KL

MSM

ILZ

KLASS Sel

FHDA PG

Ikhlas

DIC Pahang

Online Outreach

Social Network

Community Workshop

HIV Anonymous Screening and STI Testing

Non reactive Result

Reactive Result

Negative Result

Positive Result

Confirmatory Testing

Treatment & Care

Continuum of Care using an innovative, client-focused community

case management approach

Case Management Flow

DiagnosedLinked to

CareRetained in

CarePrescribed

ARTVirally

Suppressed

Case Management

Find and

map

KP

Assist and

accompany

them to

testing

Assist and

accompany

them

to ART

Assist KPs to remain adherent to ART

to achieve viral load suppression

Case workers are resourced to:

Case Management – All KPsJanuary 2017- December 2017

10658KP reached

5461(51%)

underwent

HIV test

467(8.5%)

KPs tested

HIV+

131(28%)KPs on

HAART

Case Management - PWIDJanuary 2017- December 2017

4713PWID

reached

2346(50%)

underwent

HIV test

104(4.4%)

PWID tested

HIV+

27(25%)PWID on

HAART

Case Management – SW/TGJanuary 2017- December 2017

3488SW/TG

reached

1459(42%)

underwent

HIV test

66(4.5%)

SW/TG tested

HIV+

22 (33%)

SW/TG on

HAART

Case Management - MSMJanuary 2017- December 2017

2457MSM

reached

1656(67%)

underwent

HIV test

297(18%)

MSM tested

HIV+

82(28%)MSM on

HAART

What we have learned so far…

• Each KP has different approach — MSMs became visible and reachable through online Apps, SW/TG and PWID still venue based approach

• Changes in Trend — Drug use trend shifting from Injecting to non-injecting (poly-drugs) , SWs becoming more mobile and going hidden using online sex work.

• Treatment as the focus — Services are more personalised

focusing on treatment – reducing lost to follow-up. The need for continuous and structured support group sessions

• Friendly services as a branding — Friendly clinics becomes more popular among KPs because spread byword of mouth among KP networks

• Challenges - Saturated number of clients for PWIDs and SW, difficult to reach sub-group of MSM who use drugs (ChemSex), Legal barriers for PWID, SW and TG groups.

Addressing structural, legal, and social barriers

“drug laws intended to

protect have instead

contributed to disease

transmission,

discrimination, lethal

violence, and forced

displacement, and have

undermined people's

right to health”

80.3

59.4

39.9

33.3

73.2

51.2

35.732.1

0

10

20

30

40

50

60

70

80

90

General Patients HIV+ Patients PWID Patients MSM Patients

Me

an S

core

Medical Students (N=486)

Dental Students (N=658)

P=0.001 P=0.001 P=0.001 P=NS

The Future HIV Healthcare Providers: Stigma & Healthcare Students in Malaysia

P<0.0001

P<0.0001

P<0.0001

Jin et al, AIDS Care 2014

SURVEY OF FACTORS ASSOCIATED

WITH INTENT TO DISCRIMINATE

AGAINST PEOPLE LIVING WITH HIV/AIDS

(PLWHA) AMONGST HEALTHCARE

PROVIDERS IN MALAYSIA

TEE YING CHEW, ADEEBAKAMARULZAMAN, JEFFREY

A.WICKERSHAM

1) Discrimination intent among healthcare providers appears

to be lower compared to medical and dental students. - More contact, exposure, and experiences

- Higher knowledge about HIV/AIDS

- Professional code of conduct

2) Stigma-related constructs are the main factors that

contribute to discrimination intent toward PLWHA.more negative feelings toward PLWHA, greater internalized shame,

greater fear, greater stereotype and greater disagreement on PLWHA

deserve good care hold greater discrimination intent.

DISCUSSION

3) Surgical based specialties are more likely to held discrimination intent compare to non-surgical based practitioners.

- Perceived higher risk during surgical procedures

- Lack of regular clinical contact with PLWHA

- Lack of HIV-related training

- Lack of knowledge about the disease

4) Prejudice subscale was not correlated with discrimination intent

- Knowledge and experience

- professional code of conduct, therefore, despite they exhibit prejudice attitude but they do not exhibit discrimination intent toward PLWHA

DISCUSSION

CONCLUSION

• Antiretroviral therapy works

• It dramatically reduces epidemic burden and

new infections

• Scaling up of HIV responses is possible

• It has already been achieved in some nations

• Ending epidemic AIDS is entirely possible

BUT

• It requires commitment, dedication and

imagination

“Dealing effectively with HIV will require our

communities and societies to break down

longstanding prejudice, hatred, and

ignorance,” “Only when scientific advances

are matched by social and cultural progress

can this epidemic truly be contained.”

Justice Edwin Cameron