Robert M Grant,
June 2012
Maurice Cook (EM Designs Group, Inc.)
The End of
AIDS
Transmission?
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 2009
41% in Young People (ages 15-24)
The HIV Pandemic
1.2 Million
Started Therapy in 2009
2 New Infections For Everyone Starting Therapy
4
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
Cohen et al, IAS Rome 2011
Pre- vs Postexposure Prophylaxis
HIV
HIV
HIV
Postexposure
prophylaxis
0 hr
36 hr
72 hr
1 mos 3 mos 5 mos
Pre- vs Postexposure Prophylaxis
HIV
HIV
HIV
Pre-exposure
prophylaxis
0 hr
36 hr
72 hr
1 mos 3 mos 5 mos
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
Study
Population
N
Results
CAPRISA 004
Women
889
39% efficacy vaginal TFV gel
Brazil, Ecuador, Peru, South
Africa, Thailand, US
MSM
2499
44% efficacy FTC/TDF
TDF2 Study
Young men
and women
1200
62% efficacy FTC/TDF
Heterosexual
couples
4758
67% efficacy TDF
75% efficacy FTC/TDF
Women
1950
FTC/TDF = futility
5029
TDF = futility
Vaginal TFV gel = futility
South Africa
iPrEx
Botswana
Partners PrEP Study
Kenya, Uganda
FEM-PrEP
Kenya, S Africa, Tanzania
VOICE
South Africa, Uganda,
Zimbabwe
Women
FTC/TDF ongoing
Bangkok Tenofovir Study
Thailand
IDUs
2400
TDF ongoing
FACTS001
South Africa
Women
2200
TFV gel enrolling
Baeten et al, CROI 2012
Prophylactic Activity of Oral FTC/TDF
”When Detected”
Trail
iPrEx
Partners
PrEP
FEMPREP
Population
Efficacy
MSM
Men and
Women
Women
42%
Seronegative
Risk
Drug Exposure Reduction
If Drug
Detected
44%
92%
75%
81%
18%*
26%**
90%
*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
16
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