Slide 1 of 42 IAS–USA Treatment as Prevention: Evaluating the Impact of HAART Expansion The British Columbia (BC) Experience AU EDITED FINAL: Julio Montaner, MD Professor of Medicine, and Head, Div. of AIDS, University of British Columbia Director, BC-Centre for Excellence in HIV/AIDS at Providence Health Care Past President, International AIDS Society ( )

Slide 2 of 44 January 2004 Summer of 1996 Year Summer of 2000 Phase I Phase II Phase III Montaner et al, Lancet, 2010 Increasing HAART Coverage within Evolving Guidelines in BC N = 7492 by the end of 2011

Slide 3 of 44 BC: All Cause Mortality (#) Montaner et al, TasP Workshop, April 2012

Slide 4 of 44 AIDS New Cases for BC by year, Lima et al, in preparation, 2013

Slide 5 of 44 HAART Use & New HIV Diagnoses for BC by year, Lima et al, in preparation, 2013 HIV Incidence Active on HAART New HIV Diagnoses (All) New HIV Diagnoses (Ever IDU)

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Slide 10 of 44 Engagement in the Cascade of Care in BC Nosyk et al, in preparation, 2012 Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009 Supp rate: 35% [30% - 40%] for pVL ≤40c/mL x2. Supp rate: 51 & 60% for a single pVL<50 or <500c/mL, respectively. Engagement in the Cascade of Care in BC Nosyk et al, TasP Workshop, 2013 Estimate of HIV+ unknown went from 50% [38-59%] in 1996 to 14% [0 – 28%] in 2009 We used pVL ≤40c/mL x2, thus overall supp rate is: 35% [30% - 40%]. This becomes 51% & 60% if a single pVL<50 or <500c/mL are used.

Slide 11 of 44 Cascade of Care by HA Lima V, Lourenco L, et al, in preparation, 2013

Slide 12 of 44 Cascade of Care by Gender Lima et al, in preparation, 2013

Slide 13 of 44 Cascade of Care by Age Lima et al, in preparation, 2013

Slide 14 of 44 Programmatic Compliance Score Assesses the impact of non- compliance with HIV treatment guidelines on all-cause mortality PCS components include: Baseline CD4 > 200/mm3 Three CD4 in 1 st year Three VL in 1 st year Baseline resistance Recommended HAART Undetectable pVL at 9 months Failure to meet a given component add one to the score PCS predicts mortality Lima et al. PLoS ONE 7(11): e

Slide 15 of 44 PCS in BC 2000 to 2011 Lima et al, in preparation, 2013

Slide 16 of 44 TasP Monitoring in the Real World In a perfect world, all HIV infected individuals would follow the same pathway in the spectrum of engagement into care: In the real world, there is attrition between each of these steps and individuals are often lost-to-follow-up. Understanding the attrition points (leakage), and their causes are essential to optimize the effectiveness of TasP. This can only be achieved by comprehensively monitoring standardized metrics, on a longitudinal basis and accounting for multiple sources of bias and heterogeneity (i.e.: geographic, socio-demographic, risk factors, etc). HIV Infected HIV Diagnosed Linked to HIV Care Retaine d in HIV Care Need ART On ART Adherent/Sup pressed

Link 4th Intl HIV TREATMANT AS PREVENTION Workshop April 1 st to 4 th Vancouver, BC, Canada.

Slide 18 of 44 In Collaboration with PHC, VCHA, NHA, PHSA, Community, and MoH