British Columbia Centre for Excellence in HIV/AIDS Julio Montaner MD, FRCPC, FCCP, FRSC Director, BC-Centre for Excellence on HIV/AIDS, Providence Health Care Professor of Medicine and Head, Division of AIDS, University of British Columbia President, International AIDS Society IAC, 2010, Vienna Treatment as Prevention: HAART Expansion - A Powerful Strategy to Reduce AIDS Morbidity and Mortality and HIV Incidence

HAART Can Reduce HIV Transmission HAART stops HIV replication  HIV levels fall to undetectable in blood as well as in sexual fluids  Sharp reduction in HIV transmission

Prevention Strategies - Education - Change in behavoir - Harm reduction - New strategies/technology - Vaccines Existing strategies have failed to contain the global HIV pandemic

Impact of HAART on IDUs Morbidity and Mortality Incidence

Wood et al, BMJ, 2009

Whiskers represent 95% confidence intervals.

Wood et al, BMJ, 2009 Whiskers represent 95% confidence intervals.

Wood et al, BMJ, May 16, 2009

Cost Effectiveness of HAART Revisited

Unique Study Features: Population Based Free Access to HAART and Medical Monitoring Centralized Data Capture / Single Source Access to Blood Borne Dxs – BCCDC Retrospective & Prospective Phases

January 2004 Summer of 1996 Year Montaner et al, Lancet, June 18th 2010 Summer of 1996 Phase I Phase II Phase III

Incidence/yr Viral load < 50/mL (%) Acquired resistance falling Plasma viral load suppression rising

Highest HIV-1- Plasma Viral load per Year Ever on Treatment & Censoring at the time of Death or Move IDU The proportion of HIV infected IDUs engaged in care in BC with plasma viral load >1500 c/mL, as a surrogate for “high” community HIV-1-viral load, decreased from ~50% in to ~20% in 2009 (p<0.001) Non IDU Montaner et al, Lancet 2010

“Provincial Viral Load” All Patients Ever Tested for Plasma HIV-1-Viral Load in BC Censoring at the time of Death or Move

BC-CDC Report, 2009 Number of HIV tests per Year in BC

Hepatitis C, Infectious Syphilis, Genital Chlamydia, Gonorrhea, BC x Canada BC x Canada BC x Canada BC x Canada 2004

Key Findings: Overall correlation between the number of pts on HAART and the number of new HIV cases diagnosed per year was (p<0.0001) For every 100 additional patients on HAART, the number of new HIV cases decreased by a factor of 0.97 (95% CI ) ie: new HIV diagnoses fell by 3%. For every 1 log10 decrease in viral load, the number of new HIV cases decrease by a factor of 0.86 (95% CI )

Incremental net benefit (Millions of CDN $) over 30 years K Johnston et al, AIDS, 2010

Combination prevention Community Interventions Biomedical Interventions Structural Interventions HIV testing, linkage to care and expanded HAART coverage Individual and small group behavioral interventions HIV Prevention Modified from T. Coates

Thank You British Columbia Centre for Excellence in HIV/AIDS Supported by the Province of British Columbia; the Canadian Institutes of Health Research (CIHR); and the National Institute on Drug Abuse, US-NIH. Additional support has been provided by Merck, Gilead and ViiV Healthcare