TasP is not enough• Stipulated that TasP is effective in reducing

infectiousness of the treated person– But much more is required.

• TasP requires effective behavioral interventions– Testing, access, linkage, retention, adherence– Processes that occur outside of the clinic

• Prevention requires a diverse portfolio of services so that there is something attractive for everyone.– Many prevention services are more cost effective than TasP

• Social benefits are Important

CDC Cascade

MMWR December 2, 2011 / 60(47);1618-1623

SF DPH, Annual Report, 2011

Nicole Johns on 20 November 2012, Philadelphia EMA Ryan White Part A Planning Council and HIV Prevention Group.

Nicole Johns on 20 November 2012, the Philadelphia EMA Ryan White Part A Planning Council and the Philadelphia HIV Prevention Group.

Nicole Johns on 20 November 2012, the Philadelphia EMA Ryan White Part A Planning Council and the Philadelphia HIV Prevention Group.

Figure 2. Estimated trends in HIV incidence and sexual behaviour.

Phillips AN, Cambiano V, Nakagawa F, Brown AE, et al. (2013) Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART-Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS ONE 8(2): e55312. doi:10.1371/journal.pone.0055312http://www.plosone.org/article/info:doi/10.1371/journal.pone.0055312

Why is TasP not working?

• Requires engagement, testing, linkage, adherence.– Processes occur outside of clinics and clinical thinking. – Only 28% with HIV in the US are effectively treated.– Only 44% in San Francisco (a privileged setting).

• Risk compensation• In couples, a third of infections arise from outside

the primary partnership.• 10 to 50% of new infections come from acute

infections, before they can be diagnosed and treated.

The Prevention Portfolio is Diverse:

• HIV Testing and counseling• Condoms• Circumcision• Needle Exchange• Interactive client based counseling

– For adherence, for harm reduction• Treatment for Positives• PREP for Negatives• Listen to what people want

Nothing passes through condoms: Use with confidence

Learning From Prior Success

• Condom Use in Early 1980s• “Love Carefully” Uganda 1990s• Seroadaptive Behaviors Late 1990s• Common Characteristics

– Grass Roots Initiatives– Focus on immediate concerns– Motivated by Sexual and Social Goals

Risk Reduction During PREP UseBy Drug Concentration

Drug ConcentrationComensurate

with Doses

HIV Risk Reduction*

95% Confidence Interval

2 per week 76% 56% to 96%4 per week 96% 90% to >99%7 per week 99% 96% to >99%

Anderson et al, Science Translational Medicine 2012 4:151ra125

*Compared with placebo, after controlling for numbers of partners, condom use, STIs, age, site

Adequate Adherence to PREP is Feasible

DrugDetection*

Region

(%) 94% 43%

USA Non USA

Time Points

53 894

MedianTFV-DP

Level26 19

P < 0.001

*Detection of TFV/FTC/TFV-DP or FTC-TP in plasma or PBMC

Figure 2. Comparison of PrEP versus earlier ART initiation for keeping couples “alive and HIV free at 50.”

Hallett TB, Baeten JM, Heffron R, Barnabas R, et al. (2011) Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modelling Study. PLoS Med 8(11): e1001123. doi:10.1371/journal.pmed.1001123http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001123

Ways PrEP Could Enable Treatment• Decreased burden on HIV treatment programs,• Motivates HIV testing,

– Provides benefits to people hoping they are uninfected,– Seropositives may be linked into care.

• More timely identification of acute infections,– Allows earlier therapy initiation,– Enables cure research for acute infection.

• Greater familiarity with antiretroviral therapy,– A diversity of providers serving a diversity of people,– Uninfected people become aware of therapy and HIV.

• May destigmatize therapy and the people who use it.

Social Benefits

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TasP Other Prevention

Less HIV Transmission Less HIV TransmissionDecreased (non-pulmonary) TB Disease

Prevention other STI transmissionSocial empowerment of women, youth, LGBT communities, communities of color; housing, jobs, food; family planning.

Combination Prevention

A Combination of Approaches is Essential for Increasing

Uptake and Use of Prevention Methods to Levels Required to

End AIDS

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