1. Introduction to HIV New Prevention Technologies (NPTs)

2. Core Competencies for Public Health
Public Health Sciences
Assessment and Analysis
Policy and Program Planning, Implementation and Evaluation
Partnerships, Collaboration and Advocacy
Diversity and Inclusiveness
Communication
Leadership

3. Learning Objectives Describe the current state of HIV in Canada
Introduction
Describe the current state of HIV in Canada
Describe existing HIV prevention options
Describe emerging HIV prevention options and how they work
Explain why there is a need for additional HIV prevention options in Canada
Describe how NPTs fit into comprehensive prevention and complement the existing spectrum of HIV interventions
Identify means of staying informed and getting involved in NPT-related work 3

4. Section 1: HIV in Canada

5. HIV in Canada Estimated number of people living with HIV
Estimated 2,200 – 4,200 new infections in 2005
Estimated 2,300 – 4,300 new infections in 2008
44% gay, bisexual and men who have sex with men
20% heterosexual/non-endemic
16% heterosexual/endemic
17% people who inject drugs
3% gay, bisexual and men who have sex with men/people who inject drugs
26% of HIV-positive Canadians (approx. 16,900) are unaware of their status

6. HIV Prevention Treatment-as-Prevention PrEP Male and female condoms
PEP
Vaccines
Microbicides
PMTCT
HIV Prevention
Behaviour change
Male circumcision
Clean injecting equipment
Voluntary counselling and testing

7. Section 2: Why are new HIV prevention options needed?

8. Why are new HIV prevention options needed?
Many people want to be able to conceive—which is not possible with male and female condoms.
Receptive partners—whether male or female—are at highest risk in sexual encounters, and often require prevention options that they can better control.
Many people are unable or unwilling to use condoms.
We need HIV prevention tools that:
allow conception
are more within the control of receptive partners
enhance pleasure
do not form a physical barrier
Experience of contraception:
More options = more protected sex acts

9. Can’t we just promote condoms?

10. Can’t we just promote condoms?

11. Efficacy vs. effectiveness
Efficacy = how well a product works under ideal conditions
Effectiveness = how well a product works in practice
For example, condom efficacy is 80-95% when used consistently and correctly. Their effectiveness is 69% because some people don’t always use them correctly or consistently.

12. Condoms and NPTs

13. Condoms and NPTs

14. Condoms and NPTs

15. Section 3: NPTs as part of a comprehensive approach

16. NPTs as part of comprehensive approach to HIV Prevention

17. Imagine a full spectrum of interventions
Male & female condoms and lubricant
Treatment to prevent vertical transmission (PMTCT)
Clean injecting equipment
Post-exposure prophylaxis (PEP)
Vaginal & rectal microbicides
Addressing social determinants of health
Rights-focused behaviour change
Voluntary counselling & testing
Sexually transmitted infection screening and treatment
Male medical circumcision
Pre-exposure prophylaxis (PrEP)
Preventative vaccines
Antiretroviral treatment
Treatment for opportunistic infections
Basic care/nutrition
Prevention for positives
Education and rights- focused behaviour change
Therapeutic vaccines
Functional cure

18. Section 4: New HIV Prevention Technologies

19. HIV Prevention Treatment-as-Prevention PrEP Male and female condoms
PEP
Vaccines
PMTCT
HIV Prevention
Male circumcision
Clean injecting equipment
Voluntary counselling and testing

20. What are “new” HIV prevention technologies?
Preventive vaccines
Vaginal and rectal microbicides
Pre-exposure prophylaxis
Treatment-as-prevention
Medical male circumcision
Non-occupational PEP
Female condoms
Diaphragm/cervical barriers
HSV-2 treatment
Still in trials
Proof-of-concept, but need to confirm efficacy
Recently proven effective but not yet (widely) available

21. Antiretroviral (ARV)-based Prevention Methods
Prior to exposure
Point of exposure
After exposure
Preventing vertical transmission (PMTCT)
PrEP
Vaginal and rectal microbicides
Treatment-as-prevention
PEP

22. HIV prevention Not ARV-based ARV-based Male & female condoms
Circumcision
Clean injecting equipment
Vaccines
Voluntary counselling and testing
Behaviour change
Vaginal and rectal microbicides
Preventing vertical transmission
PEP
PrEP
Treatment-as- prevention

23. Treatment-as-prevention
The prevention benefits that come from HIV+ people using ARVs
Treatment = less virus = less transmission
Alternative names and concepts:
Test and Treat (or TNT)
Seek and Treat
TLC+

24. What we know about treatment-as-prevention
Works at the individual level
One trial among mostly heterosexual serodiscordant couples showed a reduced risk of transmission if HIV+ partner is on treatment.
Can it work at the population level?
Increased testing = more knowledge of status = less risk-taking
Increased testing = more HIV+ people on treatment = less virus
Less risk-taking + less virus = less transmission?

25. Questions about “treatment-as- prevention”
ARVs for prevention
Access to treatment
Knowledge of status

26. Pre-exposure prophylaxis (PrEP)
The ongoing use of one or two antiretrovirals by HIV- negative individuals starting before an exposure and continuing afterwards
Infection does not occur instantly after an exposure to HIV. The virus needs to spread throughout the body— this may take up to 3 days after the exposure.
The “window of opportunity” for PrEP: after an exposure HIV has not yet spread throughout the body. During this time, PrEP may be able to stop HIV from causing an infection.

27. What we know about PrEP
Using either the ARV tenofovir (Viread) or tenofovir+emthricitabine (Truvada) in combination with a comprehensive package of prevention services:
One trial showed that PrEP (using Truvada) reduces the risk of infection when used by gay men and other MSM, and trans women.
Two trials showed that PrEP (using either Viread or Truvada) reduces the risk of infection when used by heterosexual men and women.
Two trials could NOT show that PrEP (using either Viread or Truvada) reduces the risk of infection when used by heterosexual women.
Effectiveness is linked to adherence.
The risk of side effects, toxicity, and drug resistance are low.

28. Questions about PrEP Safety/effectiveness of…
a pill taken on a non-daily schedule
other antiretrovirals
Safety/effectiveness of Viread and Truvada…
among women
in populations not included in trials
over a longer period of time
in the “real world”
PrEP has not yet been approved by Health Canada, but may already be in use off-label.

29. Vaginal and rectal microbicides
A lube used before and during sex
A douche or enema used before and/or after sex
A vaginal ring that stays in place for up to a month
A suppository or a gel applied with an applicator before sex

30. What we know about vaginal microbicides
Using a gel with the ARV tenofovir, in combination with a comprehensive package of prevention services:
One trial showed that vaginal use of tenofovir gel before and after sex reduced the risk of infection when used by heterosexual women.
One trial was unable to show that daily vaginal use of tenofovir gel reduced the risk of infection when used by heterosexual women.
Efficacy is linked to adherence.
The risk of side effects, toxicity, and drug resistance are low.
We need microbicides that:
are both contraceptive and not contraceptive
are inexpensive and easily available
can be used without a partner’s active cooperation

31. Questions about vaginal and rectal microbicides
Will we have microbicides that:
help reduce the risk of getting other sexually transmitted infections?
can be used vaginally or rectally?
can be used by HIV+ people (products not based on ARVs)?
Will we have rectal microbicides?
Related question: Are currently available (non-microbicide) lubricants safe?

32. Vaccines
A substance (i.e. part of the virus) that teaches the body to recognize and defend itself against bacteria and viruses
Causes a response from the immune system—preparing it to fight if exposed to a specific infection
Not a cure
Prevents infection or slows disease progression

33. What we know about vaccines
Encouraging signs include:
broadly neutralizing antibodies found.
precedent for other diseases: success against other viral infections.
precedent from animal studies: long-term control of infection in vaccinated monkeys.
immune control of HIV-1: infected individuals control infection.

34. Questions about vaccines
Challenges remain
Need a different approach for HIV vaccines.
Animal models: have not yet accurately predicted how they will work in humans.
Correlates of protection: what immune responses will protect an individual from infection is mostly unknown.
HIV mutations
HIV subtypes: there are many different subtypes of HIV may require matching vaccines.

35. Section 5: NPT Implementation Issues

36. NPT implementation issues
Guidelines for front-line delivery should include tools and protocols regarding:
how to assess risk.
how to match NPTs with individuals and community needs.
how to support adherence and manage risk compensation.
how often to conduct HIV testing, STI screening and test for drug resistance.
how to manage side effects for clinicians and consumers.
how to communicate about partial efficacy and effectiveness.

37. NPTs: Measuring impact
Mechanisms required to measure:
safety and toxicity
adherence
risk compensation
impact on HIV incidence

38. Next Steps: Actions that can be taken
If you determine that your clients are at high risk of HIV…
Urge them to get tested for HIV and STIs regularly.
Encourage risk reduction behaviours (safer sex, harm reduction).
Remind them to seek PEP as soon as possible after a potential HIV exposure.
Suggest they talk to their doctor about HIV prevention options, including PrEP.
If you want to engage actively in shaping the field…
Urge public health officials to issue guidance on the use of NPTs.
Join a local committee or group addressing some of the social determinants putting your clientele at risk of HIV.
Become involved in street outreach, support needle exchange and harm reduction programs.
Join social justice groups fighting stigma and discrimination, homophobia, racism, and gender violence.

39. Conclusion Introduction Additional Resources:
Fact Sheets, Resources & Reports:
Webinars & Courses:
Listservs