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From efficacy to effectiveness: HIV seroincidence by ART status

among HIV discordant couples in Zambia

Kristin M. Wall, PhD

kmwall@emory.edu

Department of Epidemiology

Rwanda Zambia HIV Research Group

Emory University, Atlanta, GA, USA

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Conflict of Interest Disclosure

The authors have no conflicts of interest due to financial or personal relationships that might be perceived to cause bias.

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Acronyms for this talk

TasP: Antiretroviral treatment (ART)-as-prevention• For the purposes of this talk, ART has been provided for

therapeutic reasons only

CVCT: Couples’ voluntary HIV counseling and testing• Joint pre-test counseling• Rapid HIV testing• Joint post-test counseling

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Research evidence

Recommendations

Implement and analyze

Questions

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Research evidence

Recommendations

Implement and analyze

Questions

CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)

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Research evidence

Recommendations

Implement and analyze

Questions

CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)

CVCT WHO, 2012 (Recs 1-3)

TasP WHO, 2012 (Recs 5)

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Research evidence

Recommendations

Implement and analyze

QuestionsCVCT: WHO Recs 1-3TasP: WHO Rec 5(WHO, 2012)

Real-world TasP effectiveness in discordant couples?

CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)

CVCT WHO, 2012 (Recs 1-3)

TasP WHO, 2012 (Recs 5)

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Research evidence

Recommendations

Implement and analyze

Questions

Real-world TasP effectiveness in discordant couples?

ART adherence?

ARV resistance?

CVCT WHO, 2012 (Recs 1-3)

TasP WHO, 2012 (Recs 5)

CVCT: transmission in serodiscordant couples by 2/3 (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992)

TasP: 96% efficacy in serodiscordant couples (Cohen et al, NEJM, 2011)

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CVCT scale-up in government clinics

HIV prevalence, 15-49 year olds (DHS)

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Impact of CVCT on HIV transmission in a real-world setting

82% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)

69% reduction in transmission after CVCT

RR 0.3 (95% CI 0.2-0.6)

Cost of preventing one HIV infection with CVCT

in Zambia$392

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82% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)

Impact of CVCT on HIV transmission in a real-world setting

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73% reduction in transmission after CVCT

RR 0.3 (0.1-0.6)

83% reduction in transmission after CVCT

RR 0.2 (95% CI 0.1-0.4)

$666 to prevent one HIV infection

Teasing apart the effects of CVCT and TasP

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CVCT is effective in a real-world setting• Irrespective of preceding therapeutic ART use

– 70-80% reduction in HIV incidence, $400-$700 per infection averted

TasP is not as effective in real-world settings as in a trial among serodiscordant couples who:• Have NOT been tested and counseled together

– 30% reduction among those on therapeutic ART

Conclusions

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Future Questions: ART Adherence?

How much can retention

and adherence improve

when ART patients are

counseled with their HIV-

spouses?• ART NON-adherence: 40%1-2

• ART attrition at 1 year: ¼ 3-4

1. Sasaki et al, An Clin Mic Antimicro, 2012; 2. Birbeck, AJTMH 2009; 3. Scott et al, BMC Pub Health 2014; 4. Fox et al, TMIH, 2010

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Future Questions: ARV Resistance?

Were ARV resistant

viruses transmitted?

• ARV resistance:1-2 – 5-6% of ART naïve

1. Price et al 2011; 2; Hamers et al, JAIDS, 2010http://hivdb.stanford.edu/surveillance/map/

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Recommendations

CVCT should be promoted and provided in all settings that offer HIV testing (WHO 2012 Recommendations 1-3 of Couples’ HIV Counseling Guidelines), including:– Antenatal clinics– PITC– Community-based VCT– Household VCT

CVCT should be a priority in ART clinics (WHO 2012 Recommendation 4 of Couples’ HIV Counseling Guidelines)

Resource allocation models should include CVCT and TasP– Using real-world estimates of effectiveness

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Acknowledgements

Rwanda Zambia HIV Research Group (RZHRG) Contributors

Mubiana Inambao

M. Kakungu Simpungwe Rachel Parker

Joseph Abdallah

Nuri Ahmed

William Kilembe

Amanda Tichacek

Elwyn Chomba

Gordon Streeb

Susan Allen

Arise—Enhancing HIV Prevention Programs for At-Risk Populations

Ibou Thior

Julie Pulerwitz

Zambian Ministry of Health & District Health Management Team

CVCT Clients & Clinic Staff

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Support for this project was provided by the Canadian Government through PATH and the Department of Foreign Affairs Trade and Development. The views expressed by the authors do not necessarily reflect the views of PATH, the Canadian Government or the Department of Foreign Affairs Trade and Development. This document was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.

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Other RZHRG posters/presentations supported by PATH-Arise

Posters• TUPE167  • TUPE368 • WEPE 435• WEPE 206 

Oral poster • THAC0504

Oral abstract• THPDE0104

Arise Satellite Session, Thursday July 24th, 18:30-

20:30 in Plenary 3