Maurice Cook ( EM Designs Group, Inc.) The End of AIDS Transmission? Robert M Grant, June 2012

A Question of Money… It is still a long haul. But AIDS can be beaten. A plague that 30 years ago was blamed on man’s iniquity has ended up showing him in a better, more inventive and generous light.

The HIV Pandemic 2.6 Million New HIV Infections in % in Young People (ages 15-24)

4 The HIV Pandemic 1.2 Million Started Therapy in New Infections For Everyone Starting Therapy

Success of Test and Treat in San Francisco? Reduced Time to Virologic Suppression, Decreased Community Viral Load, and Fewer New HIV Infections, 2004 to 2009 Das et al, CROI 2011

Success of Test and Treat in San Francisco? Reduced Time to Virologic Suppression, Decreased Community Viral Load, and Fewer New HIV Infections, 2004 to 2009 Das et al, CROI 2011

Cohen et al, IAS Rome 2011

Pre- vs Postexposure Prophylaxis HIV Postexposure prophylaxis 0 hr 36 hr 72 hr1 mos3 mos5 mos HIV

Pre- vs Postexposure Prophylaxis HIV Pre-exposure prophylaxis 0 hr 36 hr 72 hr1 mos3 mos5 mos HIV

Why Chemoprophylaxis? Post- and Pre-Exposure Prophylaxis: PEP and PrEP for Seronegatives People whose partners: – May have acute infection, – Have unknown serostatus, – Are not treated, or not treated effectively. May inspire an active approach to prevention: – Reduced stigma by breaking the drug-disease link, – Options for couples. No interference with sexual practices.

The reality: PrEP efficacy trial results, March 2012 StudyPopulationNResults CAPRISA 004 South Africa Women88939% efficacy vaginal TFV gel iPrEx Brazil, Ecuador, Peru, South Africa, Thailand, US MSM249944% efficacy FTC/TDF TDF2 Study Botswana Young men and women % efficacy FTC/TDF Partners PrEP Study Kenya, Uganda Heterosexual couples % efficacy TDF 75% efficacy FTC/TDF FEM-PrEP Kenya, S Africa, Tanzania Women1950FTC/TDF = futility VOICE South Africa, Uganda, Zimbabwe Women5029 TDF = futility Vaginal TFV gel = futility FTC/TDF ongoing Bangkok Tenofovir Study Thailand IDUs2400TDF ongoing FACTS001 South Africa Women2200TFV gel enrolling Baeten et al, CROI 2012

Prophylactic Activity of Oral FTC/TDF ”When Detected” TrailPopulationEfficacySeronegative Drug Exposure Risk Reduction If Drug Detected iPrExMSM 42%44%92% Partners PrEP Men and Women 75%81%90% FEMPREPWomen 18%*26%** *Pre-specified “as treated” analysis through visit of last dose. ** Drug detected in seronegatives at both of 2 timepoints. Anderson CROI 2012; Baeten CROI 2012; Donnell CROI 2012; Van Damme CROI 2012;

Summary of Evidence of No or Low Drug Exposure Among Active Arm Seroconverters: iPrEx, Partners PrEP No suppression of plasma viral RNA No selection for drug resistance No detectable drug in 91% – Low levels of drug in the others

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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. 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.

Combination Prevention