1. PWP Recommendations:
Treatment As Prevention
John T. Brooks, MD
2011 National HIV Prevention Conference
August 14-17, 2011 – Atlanta, GA
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of HIV/AIDS Prevention

3. Outline
Methods
Review data
Review US existing recommendations
Proposed PwP recommendation

4. Methods
Recommendations based on:
Epidemiologic data
• Reduction in HIV transmission risk associated with ART1
HIV treatment recommendations
• U.S. Department of Health and Human Services (2009)
• International AIDS Society–USA Panel (IAS-USA – 2010)
Consultation and narrative review for other aspects

5. Data Review: History of Research
Observational cohort data
Suggested association low viral load (cause) reduce risk (effect)
Modeling studies
Suggested intervention (treating HIV infection) could reduce epidemic
Ecological analyses (community-based observations)
Treating a population associated with reduction in new infections
Biomedical research
Established mechanism and biological plausibility of intervention
Randomized clinical trial
Demonstrated intervention was effective

6. Low plasma viral load in sexual partner associated
with significantly decrease risk of HIV transmission
Quinn et al. NEJM 2000, 342:921

7. Meta-analysis indicated ART’s reduces sexual
transmission of HIV in serodiscordant couples
11 cohort studies
92% reduction in HIV transmission risk: from 5.64 to 0.46 events/100 py
Attia et al. AIDS 2009, 23(11): 1397-1404

8. Mathematical modeling suggested universal
“test and treat” strategy could control the epidemic
Incidence
1980 2000 2020 2040
Prevalence
1980 2000 2020 2040
Granich et al. Lancet 2009, 373:48-57

9. Decreasing “community viral load” and
HIV diagnoses in San Francisco
Das et al. PLoS ONE 2010, 6(5):e11068

10. Decreasing “community viral load” and
HIV diagnoses in British Columbia…
Period of
“HAART expansion”
Maybe folks in BC are
simply reducing number of partners and
using condoms more consistently and correctly?
Montaner et al. Lancet 2010, 376:532--539

11. …despite increasing rates of syphilis and gonorrhea
Infectious Syphilis, 1999-2008 Gonorrhea, 1999-2008
x Canada
• BC
x Canada • BC
Modified from http://www.phac-aspc.gc.ca/std-mts/report/sti-its2008/index-eng.php

12. Viral load in plasma and genital secretions correlated,
and each are correlated with risk of transmission
2,521 serodiscordant African couples
: 73 men seroconverted in 1,805 couples
Women Women
CVL plasma
: 40 women seroconverted in 716 couples
Men Men
semen plasma
Baeten et al., Sci Trans Med 2011, 3(77): 1

13. HPTN 052:
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
1,763 heterosexual couples
HIV discordant
CD4 count 350-500 cells/mm3
886 couples: “early therapy” 887 couples: “delayed therapy”
Infected partner initiates at: Infected partner initiates at:
CD4 count 350-500 cells/mm3 CD4 count < 250 cells/mm3
or AIDS-related illness
Primary Outcomes:
• HIV incidence in HIV-uninfected partners
• HIV-associated clinical events
Cohen et al., N Engl J Med 2011, 365: 493-505

14. HPTN 052:
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
“The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1
and clinical events, indicating both personal and public health benefits from such therapy”
Early: 1 Early: 40
Delayed: 27 Delayed: 65
96% reduction 41% reduction
Cohen et al., N Engl J Med 2011, 365: 493-505

15. Existing US Recommendations
DHHS (last updated January 2011):
CD4 350-500 cells/mm3 – Recommend use
CD4 >500 cells/mm3 – Optional use, not contraindicated
ART for prevention – “Use of effective ART regardless of CD4
count is likely to reduce transmission to the uninfected sexual
partner”

16. Caveats and Considerations
to PwP Recommendations
Existing data limited mostly to heterosexuals
Feasibility: limited capacity and financing
Ethics of individual vs. population health:
→ Treating the patient for her/his own health
must always be the first priority

17. Recommendations
Clinical care and community settings:
HIV-infected persons should be made aware of individual health
benefits and risks of ART, benefit of ART in reducing the risk of HIV
transmission, and the need to continue other prevention measures
while taking ART (see Risk Reduction section).
HIV-infected persons with ongoing HIV transmission risk behavior
despite risk-reduction measures should be offered ART regardless of
CD4 lymphocyte count for the potential reduction in HIV transmission
risk as well as potential individual health benefit. (HIV transmission
risk behavior is defined in the Risk Screening section.)
HIV-infected persons initiating or continuing ART should be made
aware of the need to continue other prevention measures while on
ART (see Risk Reduction section) and the importance of adherence
(see Adherence section).

18. Recommendations
Clinical care settings:
ART should be initiated for those individuals willing and able to
commit to long-term ART.
ART regimen selection should be guided by current ART
recommendations for the optimal health of the HIV-infected individual
and with greatest success of suppressing plasma viremia.

19. John T. Brooks
zud4@cdc.gov