1. Global overview of the state of the epidemic and new strategies of Response Peter Godfrey-Faussett, Senior Science Adviser, UNAIDS Karl Dehne, Chief, Prevention, UNAIDS National Consultation on Combination Prevention, Lima, Peru 12-14 November 2014

2. Adults and children estimated to be living with HIV  2013 Eastern Europe & Central Asia 1.1 million [980 000– 1.3 million] North America and Western and Central Europe 2.3 million [2.0 million – 3.0 million] Middle East & North Africa 230 000 [160 000 – 330 000] Caribbean [230 000 – 280 000] 250 000 Asia and the Pacific 4.8 million [4.1 million – 5.5 million] Sub-Saharan Africa 24.7 million [23.5 million – 26.1 million] Latin America 1.6 million [1.4 million – 2.1 million] Total: 35.0 million [33.2 million Source: UNAIDS – 37.2 million]

3. Chapter One A disease sin nombre 1981 Slim’s disease Pneumocystis pneumonia 1983 1984

4. Prologue Man and the Environment

7. Chapter Two “Before the life boat” www.youtube.com/watch?v=7kYrMw14cDQ

9. Chapter Three Beyond the triumph of biomedicine

11. Chapter Four Treatment and Global Solidarity

12. Global number of people living with HIV & HIV-related deaths: Changes post-2005 Source: UNAIDS Global Report 2014

13. Chapter Five A Prevention Revolution?

14. Community driven approaches & movements Biomedical tools & Interventions Structural changes & political HIV/STI Testing & Linkage to Care Individual & Small Group behavioral strategies Combination prevention Adapted from Coates Lancet; 2008 COMBINATION Prevention for Maximum Effect

15. ●Barrier protection ●Circumcision ●PreP - Oral - Topical (Gel, Film, Ring) - Injectable Barrier protection Blood screening Harm reduction for PWID ART Maternal-to-child transmission Decrease partner’s viral load Treatment of acute HIV infection HIV Prevention: Increasing Choices ●Condom promotion ●Individual-level interventions ●Couples interventions ●Community-based interventions ●Structural interventions Decrease Source of HIV Infection Decrease Host Susceptibility to HIV Infection Alter Behavior: Exposure, Adherence.

16. Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is on sexual transmission Behavioural Intervention -Abstinence -Be Faithful HIV Counselling and Testing Coates T, Lancet 2000 Sweat M, Lancet 2011 Male Condoms Female Condoms Treatment of STIs Grosskurth H, Lancet 2000 Male circumcision Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Treatment for prevention Cohen M, NEJM, 2011 Donnell D, Lancet 2010 Tanser, Science 2013 Microbicides for women Abdool Karim Q, Science 2010 Grant R, NEJM 2010 (MSM) Baeten J, NEJM 2012 (Couples) Paxton L, NEJM 2012 (Heterosexuals) Choopanya K, Lancet 2013 (IDU) Oral pre-exposure prophylaxis Post Exposure prophylaxis (PEP) Scheckter M, 2002 ARV prophylaxis ARV prophylaxis HIV PREVENTION

17. Consider…. Consider a future time in which there are multiple prevention options available And those who use prevention tend to use consistently, but not everyone is perfect Contraceptive choices, Swaziland 2013 Source: UNFPA Consistency of contraceptive use, USA Source: Guttmacher Institute

18. Chapter Six HIV in 2014

19. Despite impressive progress, the spread of HIV has yet to be controlled! In 2013, there were: Source: UNAIDS Global Report 2014 1.5 million HIV deaths 35 million living with HIV 2.1 million new infections

20. 3 Key Challenges 1.Dysfunctional health systems – Failing to convert efficacious treatment & prevention interventions fully for maximum effectiveness 2.Most new HIV infections now occur in Key Populations – the highest prevention priority – Young women in Africa – Sex Workers – MSM & Transgender individuals – IDU 3.Stigma, discrimination & legislative hurdles – Major obstacle to prevention & care 34 years on: AIDS is still far from over

21. Despite Scientific Progress, Insufficient Decline in New Infections Globally Sexual health promotion Combination prevention Advocacy for prevention revolution Accelerated action, focus and innovation Targets

22. Two global sub-targets are being proposed: 1.By 2020, new infections in key populations will be reduced by 75% 2.By 2020, new infections in young women and girls will be reduced by 75%

23. 75% Reduction in New Infections: Can Peru make it?

24. Programmatic Targets that need to be reached to achieve 75% reduction (UNAIDS modelling results) Key populations reached with comprehensive service packages, including condoms – Assumed to translate in 80-90% consistent condom use MSM and sex workers access PrEP Viral suppression of all PWHIV – 90:90:90 cascade 85% 10% 70%

27. Possible factors sustaining high HIV incidence in gay men and other MSM Insufficient programme coverage of traditional outreach programmes Expansion of social and sexual networks – those newly connected hardly reached Systemic conditions (like persistent stigma) Possible changes in perception of HIV among MSM

28. Too few MSM reached by HIV prevention services Source: the World Bank

29. 29 ( Almost) all persons attend an NHS clinic Annual follow up data (cd4, VL, ART) (SOPHID) Linked by soundex to previous years to form national cohort Data used to inform Diagnosed Prev trends Clinical outcomes Testing policies Undiagnosed infection TAsP National cohort of Persons seen for HIV care = Prevalence of diagnosed HIV infection

30. 30 HIV care provided through the National Health Service, UK Among 81,500 persons living with diagnosed HIV 97% are linked to care after diagnosis within 3 months 95% are retained in care annually 92% of persons in need of treatment are on treatment (87% of all diagnosed) 95% of persons on treatment achieve VL<200 copies/ml

31. HIV in the UK: 2013 Presentation title - edit in Header and Footer HIV diagnoses, AIDS & deaths 6,000 new HIV diagnoses reported 42% diagnosed late 319 reports of AIDS 577 deaths – 75% are late diagnosed Incidence in MSM remains high with no sign of a decline (Birell, Phillips)

32. People living with HIV by diagnostic and treatment status, and number with detectable viral load, UK, 2006-2012 27% 26% 24% 23%22%

33. Whole system approach to prevention and care Evidence that particularly sexual risk taking behaviour can only be addressed by tackling syndemic factors including depression, substance use, violence, sexual stigma, homophobia and poverty

34. Syndemic conditions associated with increased HIV risk in a global sample of MSM Substance use

35. Socio-political context Legal (human rights, anti-discrimination, drug laws, access to healthcare) High level of stigma and discrimination despite human rights laws Access to ARV – cost, procurement process, stock-outs, limited regiments Affordable diagnostics and resistance testing Structural barriers – greater need for integrated health care aimed at most at risk communities, provision of sex education in schools Cultural barriers – providing friendly, non judging services in partnership with NGOs 35

36. Community engagement Stigma and discrimination remains major barrier to testing, link and retention in care and prevention efforts Need greater engagement of PLHIV and affected communities at every level Tailored messages for individuals recognising diverse nature of community Supporting peer-led initiatives and outreach programs Sustained funding for NGOs Provision of integrated and welcoming, non judging services in partnership with NGOs 36

38. Changes in perception of HIV? Gay health summit looks at life beyond HIV (14 Nov 2013) A speaker stressed the importance of intergenerational dialogue, and recalled an exchange: “The older men were chastising the younger men who admitted they chose not to use condoms regularly since they perceived that condoms were a barrier to the intimacy they sought in sex,” he said. “One of the older men said in response to this that ‘every time you do that you are asking to die.’ “So one of the younger men countered, ‘we can’t keep being afraid of sex because you were. We can’t carry the burden of everyone who died before us.’ Andrew Shopland says many of the young men who he works with at Mpowerment long for community. Really what we’re looking for is connection and acceptance, he told the summit. http://dailyxtra.com/vancouver/news/gay-health-summit-looks-at-life-beyond- hiv?market=210http://dailyxtra.com/vancouver/news/gay-health-summit-looks-at-life-beyond- hiv?market=210

39. Connectedness with gay subculture in repeated web surveys: behavioural surveillance among MSM in Germany What % of MSM is using dating apps/web-based dating in Peru?

40. New media technology Where people meet partners Where people get information Apps may enhance self-assessment of risk Monitoring PrEP adherence

41. Optimized service delivery: All-in-One Chain model Example of the city-approach in Chengdu city, China Out reach Peer education Venue & Internet based intervention Community VCT Venue based rapid testing Psychological support Community follow up Partner test promotion CD4 test Compliance education Guide for medicine & nutrition Positive prevention Testing Follow up Treatment & Care

42. Integrating community systems Mapping of available services Provider Sensitization Capacity building of community-based organizations Formalize referral system Linkages with interactive internet - based platforms Collaborate with gay community on monitoring of quality of services Collaborate on advocacy and programming within local government

43. Missing links and typical gaps Reach of young gay men, hidden/unknown networks, those only connected virtually, not gay self-identified MSM, outside main cities Retention in programs of those testing negative Condoms and lubricants! Link to anal health and other clinical services PreP, as part of comprehensive combination strategy

44. Possible results framework Service coverage through Community-led outreach Coverage with facility-based services Outreach coverage with service packages including condoms and lubs Reach with interactive new media and referrals Community- based testing and retention Facility-based HTC PrEP ART Community empowerment and mobilization, other enablers and synergies

45. Conclusion Ambitious prevention targets achievable in principle! Concept of combination prevention remains valid! Wide programme gaps – need to expand reach and keep those reached engaged Condoms and lubs remain cornerstone of combination prevention, but additional options, PreP (and early initiation of treatment) needed! Social and digital media Strengthen linkages between community and facility based services and virtual space Community empowerment critical Domestic funding, including city approach!

46. Chapter Seven HIV beyond 2015

47. Choosing a future… The End of AIDS “The End of AIDS” is an aspirational vision Epidemiological concepts of elimination and eradication not readily applicable to AIDS as millions are living with HIV and no cure available Key step to “The End of AIDS” is epidemic control – Epidemic control - Reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate intervention measures – Point where HIV no longer represents a public health threat and no longer among the leading causes of country’s disease burden – Mathematically defined as the point at which the reproductive rate of infection (R 0 ) is below 1

48. What will it take to reach the ambitious target of epidemic control? Act on knowledge of detailed local epidemiology Build on successes ….learn from failures ….implement to scale As the HIV epidemic changes – so too should our programs & interventions. Adapt with the changes! Target hotspots, pockets and key populations that continue to sustain high HIV incidence – will need combinations of appropriate prevention strategies Deal with underlying drivers such as legal barriers, stigma & social norms simultaneously Continued funding & greater program efficiency Biomedical, socio-behavioural and implementation science, incl. innovations

49. Epilogue A world without HIV?

50. Acknowledgements Salim Abdool Karim, Chair, UNAIDS Science Panel Valerie Delpech, Epidemiologist Public Health England Jared Baeten, Partners PrEP, University of Washington