CityAge: The Data Effect Vancouver

1. Slide 1 of 42
Treatment as Prevention
The Key to an AIDS & HIV free Generation
or
Harnessing the Full Power of
Administrative and Clinical Data
Julio Montaner, MD
Professor of Medicine, and Head, Div. of AIDS, University of British Columbia
Director, BC-Centre for Excellence in HIV/AIDS at Providence Health Care
Past President, International AIDS Society (2008-2010)
AU EDITED FINAL: 03-18-13
IAS–USA

2. Slide 2 of 44
USA - Trends in Annual Rates of Death
Deaths per 100,000 Population
Ages 25 to 44
40
Unintentional
injury
Cancer
35
30
Heart
disease
Suicide
25
20
15
HIV infection
10
Homicide
5
0
82
84
86
88
Year
90
92
94
Chronic liver
disease
Stroke
Diabetes

3. Vancouver 1996
“One World One Hope”

4. Impact of HAART in BC-CfE
140
Death Rate per 1000
Life Expectancy at age 20
35
120
30
100
25
80
20
60
15
40
10
20
5
0
0
1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
1993-94
1995-96
1997-98
1999-00
2001-02
2003-04
Modified from Hogg et al, Lancet. 2009

5. New HIV and Syphilis in BC
BC-CDC, 2005

7. HAART stops HIV replication
↓
HIV load falls to undetectable levels in plasma
as well as in sexual fluids
↓
Sharp reduction in HIV transmission

8. TasP is Cost-Averting
“HIV deficit” in BC in 2005: 400
Cost of Medical Management of 1 HIV infection over a
lifetime = $250,000
800 cases per year
Averted lifetime Rx cost up to 2001 US $96.4M
A total of 3,963 pts were on HAART in BC in 2005
400 cases per year
Total actual drug cost (using patented drugs) in 2005
$49 million US

9. TasP is Cost-Averting
“HIV deficit” in BC in 2005: 400
If the cost of Medical Management of 1 HIV infection
over a lifetime is about $250,000
Averted lifetime Rx cost up to U$A 100M
A total of 3,963 pts were on HAART in BC in 2005
Total actual drug cost (using patented drugs) in 2005
U$A 50M

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

11. Increasing HAART Coverage within
Evolving Guidelines in BC
N = 7492 by the
end of 2011
January 2004
Summer of 2000
Summer of 1996
Phase I
Phase II
Year
Phase III
Montaner et al, Lancet, 2010

12. BC: All Cause Mortality (#)
All
Cause
Mortality
in
BC
400
350
300
Frequency
250
200
150
100
50
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Years
Montaner et al, TasP Workshop, April 2012

13. Slide 13 of 44
AIDS New Cases for BC by year,
1996-2011
16$
16$
14$
Rate%per%100,000%popula.on%
Rate%per%100,000%popula.on%
14$
12$
12$
10$
10$
8$
8$
6$
6$
4$
4$
2$
2$
0$
AIDS$0$BCCDC$Rate$
0$
1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$
6.9$ 4.3$ 4.4$ 4.2$ 4.3$ 2.5$ 3.2$ 3.3$ 3.1$ 3.1$ 2.8$ 2.6$ 2.7$ 2.1$ 1.6$ 1.4$
1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$
AIDS$and$CD4$Rate$
AIDS$0$BCCDC$Rate$
15.6$ 9.8$
6.9$ 4.3$
AIDS$0$BCCDC$Cases$
AIDS$and$CD4$Rate$
269$ 9.8$ 8.9$ 8.6$ 8.1$ 6.9$ 7.8$ Montaner et 7.6$ 110$ 118$ 5.5$ 4.5$ 3.8$
15.6$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ Under Review, 2013
8.4$ 7.7$ 8.3$ al, 7.6$ 7.1$ 93$ 72$ 64$
AIDS$and$CD4$Cases$
AIDS$0$BCCDC$Cases$
HIV0related$Mortality$Rate$
AIDS$and$CD4$Cases$
8.9$
4.4$
8.6$
4.2$
8.1$
4.3$
6.9$
2.5$
7.8$
3.2$
8.4$
3.3$
7.7$
3.1$
8.3$
3.1$
7.6$
2.8$
7.6$
2.6$
7.1$
2.7$
5.5$
2.1$
4.5$
1.6$
3.8$
1.4$
604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$
269$ 170$ 177$ 168$ 172$ 101$ 131$ 137$ 130$ 130$ 117$ 110$ 118$ 93$ 72$ 64$
6.5$ 3.0$ 2.8$ 2.6$ 3.0$ 2.7$ 2.6$ 3.1$ 2.5$ 3.5$ 3.3$ 2.3$ 1.8$ 1.4$ 1.2$ 1.3$
604$ 386$ 355$ 343$ 329$ 280$ 319$ 348$ 318$ 347$ 321$ 329$ 311$ 246$ 205$ 176$

14. BC: HIV Prevalence and TB Incidence
James
Johnston,
in
prepara/on,
May
2013

15. 800$
Slide 15 of7000$
44
Number$of$new$cases$and$new$diagnoses$
Number$of$new$cases$and$new$diagnoses$
500$
500$
400$
400$
300$
300$
HIV Incidence
New HIV Diagnoses (All)
New HIV Diagnoses (All)
200$
200$
100$
4000$
4000$
3000$
3000$
2000$
1000$
100$
0$
HIV$Incidence$
HIV Incidence
Number$os$individuals$on$HAART$
Number$os$individuals$on$HAART$
HAART Use and
HIV
new
Diagnoses
HAART
use
& New HIV Diagnoses7000$
800$
700$
Bri/sh
by year, 1996-2012HAART
012
on
Active
for BC Columbia,
1996
-­‐
2Diagnoses6000$
HAART Use & New HIV
700$
6000$
600$
5000$
for BC by year, 1996-2012
600$
5000$
Active on HAART
New HIV Diagnoses (Ever IDU)
New HIV Diagnoses (Ever IDU)
1000$
0$
1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$ 0$
0$
1996$ 1997$ 1998$ 1999$ 2000$ 2001$ 2002$ 2003$ 2004$ 2005$ 2006$ 2007$ 2008$ 2009$ 2010$ 2011$ 2012$
632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$
HIV$Incidence$
New$HIV$Diagnoses$
632$ 551$ 490$ 461$ 461$ 476$ 489$ 495$ 490$ 472$ 446$ 418$ 408$ 387$ 382$ 380$ 368$
702$ 519$ 471$ 416$ 400$ 420$ 418$ 408$ 442$ 400$ 361$ 391$ 345$ 337$ 301$ 289$ 238$
New$HIV$Diagnoses$(ever$IDU)$ 352$ 215$ 177$ 159$ 152$ 132$ 156$ 136$ 137$ 125$ 115$ 118$ 345$ 337$ 301$ 289$ 238$
New$HIV$Diagnoses$
702$ 519$ 471$ 416$ 400$ 420$ 418$ 408$ 442$ 400$ 361$ 391$ 65$ 64$ 52$ 34$ 29$
AcAve$on$HAART$
New$HIV$Diagnoses$(ever$IDU)$ 837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$
352$ 215$ 177$ 159$ 152$ 132$ 156$ 136$ 137$ 125$ 115$ 118$ 65$ 64$ 52$ 34$ 29$
HIV$Prevalence$
AcAve$on$HAART$
7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$
HIV$Prevalence$
7900$ 8228$ 8593$ 8933$ 9150$ 9408$ 9690$ 9936$ 10216$ 10398$ 10566$ 10790$ 11040$ 11280$ 11500$ 11700$ 11972$
837$ 1960$ 2596$ 2994$ 3079$ 3120$ 3211$ 3356$ 3585$ 3913$ 4256$ 4654$ 5123$ 5595$ 5999$ 6298$ 6260$
Updated
from
Montaner
et
al,
Lancet,
2010

16. Slide 16 of 44
HIV+
Birth
1
1

17. Slide 17 of 44
HIV Diagnoses by Region and Year
!
20
Public Health Agency of Canada
!
HIV Diagnoses
per 100,000 Population
B.C.
Sask.
15
Ontario
10
5
0
Manitoba
Ontario
B.C.
Québec
Alberta
Québec
Alberta
Manitoba
Sask.
Atlantic
1995
Atlantic
1998
2001
2004
2007
2010
Hogg et al, HIV Medicine, 14, 581-2, 2013
Year

18. When to start: Potential scenarios
Estimated millions of people eligible for ART
in lower & middle-income countries in 2011
15
23
>25
11
1
CD4
≤
200
Recommended
Since 2002
2
CD4
≤
350
+
3
4
CD4
≤
500
CD4
≤
350
+
Expanded
CD4
independent
condi6ons
ART
regardless
of
CD4s:
HIV-­‐SD
couples
TB/HIV
HBV/HIV
Pregnant
women
Children
≤
5yo
Slide 18 of 44
32
5
Test and treat
All
HIV+
-­‐
•
•
•
•
International AIDS Society Conference, KL, July 2013

19. Slide 19 of 44
Status Quo 2011
Enhanced Investment 2012
2013 WHO Guidelines
2013 WHO Guidelines plus Optimized PrEP and HIV Vaccine
Manuscript
under
preparaGon

20. Slide 20 of 44
Lives Saved (x 1,000)
Granich et al
U$A Billions

21. Slide 21 of 44
Treatment 2.0:
A new
preventiontreatment
paradigm in the
global response
to HIV/AIDS
UNGASS
New York - 9 June 2010

22. Slide 22 of 44
Feb 2011: China Embraces TasP
February 24th 2011

23. Slide 23 of 44
Oct 3rd 2013
Oct 17th 2013
Few could have imagined that we’d be talking about the real possibility of an
AIDS-free generation. But that’s what we’re talking about…make no mistake,
we are going to win this fight.
President Obama, December 1, 2011
PS: By the end of 2013, PEPFAR will directly support more than 6 M people on HAART– 2M more
than previously targeted.

24. Slide 24 of 44
"To cut new infections in half, we'll have to heed Julio Montaner's years of pleas to implement
Treatment as Prevention and implement combination prevention programs. We can save a lot of lives
if all this is done..."
President Clinton, Washington AIDS Conference, 2012

25. Slide 25 of 44

26. Premier
Christy
Clark
announces
AIDS
2015
-­‐
The
8TH
IAS
Conference
on
HIV
Pathogenesis,
Treatment
and
Preven/on,
Vancouver,
July
2015
July
3rd
2013
|
Kuala
Lumpur,
Malaysia