HIV Treatment as Prevention:

Is this the end of HIV?

David Holtgrave, PhD

Professor and Chair

Dept. of Health, Behavior & Society

AS A NATION, DO WE AND WILL WE PROVIDE NECESSARY HIV CARE AND TREATMENT?

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Gardner treatment cascade

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From: Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011 Mar 15;52(6):793-800.

CDC MMWR, November 30, 2011

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From: Vital Signs: HIV Prevention Through Care and Treatment — United States. MMWR. 2011;60:47. 1618-1623.

ADAP Waiting Lists are the Tip of the Iceberg

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http://coastal.er.usgs.gov/ocean-acidification/arcticcruise2011/journal/index.php/2011/08/20/icebergs/

In 2004, IOM Panel calls for HIV care entitlement program…

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“COMBINATION PREVENTION” HAS SADLY BECOME

“SUBSTITUTION PREVENTION” WHEN WE NEED

“SYNERGISTIC PREVENTION”TO URGENTLY IMPACT INCIDENCE

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HIV is transmitted during an act of unprotected risk behavior in a serostatus discordant partnership with virus present

In a serostatus discordant partnership…..

Unprotected transmission relevant risk behavior present

No unprotected transmission relevant risk behavior

Unsuppressed Viral Load Concentration of transmission

Essentially no transmission

Suppressed Viral Load Essentially no transmission Essentially no transmission

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Key US populations defined by HIV serostatus and relevance of various treatment-related prevention approaches

9 © 2009, Johns Hopkins University. All rights reserved.

From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

Number of forward HIV transmissions from subgroups of persons living with HIV, and potential points of prevention intervention

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From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

Key services needs of the three subpopulations of persons living with HIV

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From: Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav. 2012 Apr 11. [Epub ahead of print].

Incidence of HIV under various scenarios

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Incidence

200003000040000500006000070000

Year

Inci

denc

e

Flat TR Comparator

S694YMC

S694YFSC

S694NMC

S694NFSC

S807YMC

S807YFSC

S807NMC

S807NFSC

Holtgrave et al., under review (please do not reproduce)

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