2. Intro to „Test and Treat‟
Most people in HIV treatment (ART) reach
undetectable VL
People with undetectable viral load are significantly
less likely to transmit virus
Collectively, individuals with lower VL lead to
communities with lower community VL = less
transmissions
Failures in the system of care pose barriers to full
success of T&T:
Late diagnosis
Non-linkage or flawed linkage to care
Insufficient use of ART
Non-adherence to ART
3. Test and Treat Components
(HRSA)
Testing and identification of PLWHA as soon as
possible
Linkage of people testing positive for HIV to HIV
care
Patient education to encourage self management
and facilitate retention in care, adherence to
treatment, and prevention of STIs
Supportive services for promotion of sexual health
maintenance
Monitoring and evaluation of test and treat
strategy
4. Intro to Gardner‟s Research
Test and treat strategy supported by
mathematical models and epidemiological
data
Areas with high coverage of ART have
decreased incidence of HIV
HOWEVER barriers to implementation of Test
and Treat strategies have not been adequately
evaluated.
5. Objectives of Gardner‟s Review
To describe and quantify the spectrum of
engagement in HIV care
To understand how gaps in the continuum of
care affect virological outcomes in the US
To understand how to address these gaps for
Test and Treat to be successful strategy
To explore effects of interventions to improve
components of engagement in care
6. Gardner‟s Review Search
Strategy
PubMed search - cross-match of HIV or AIDS
with
Prevalence United States
Incidence United States
Late diagnosis
Linkage to care
Retention in care
Engagement in care
Adherence
Persistence
Resistance
Bibliographies of pertinent articles were
reviewed
Emphasis was based on population based
7. HIV Care Continuum
Not in HIV Care Engaged in HIV Care
Unaware of Aware of Receiving some Entered HIV Cyclical or Fully engaged
HIV infection HIV infection medical care but care but lost to intermittent user in HIV care
(not in care) not HIV care follow-up of HIV care
Adapted from
Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2
Cheever LW Clin Infect Dis 2007;44:1500-2
9. Undiagnosed HIV Infection
1.1 million in the US with HIV/AIDS
21% of those not aware HIV+ (US)
35%-45% of newly diagnosed individuals have
AIDS within 1 year (US)
12. Linkage in Care
Longer delays in linkage with medical care are
associated with greater likelihood of
progression to AIDS by CD4 criteria
HIV+ people not linked to care pose a greater
risk of transmission
Gardner concludes that ~75% of newly
diagnosed HIV+ people successfully like to
HIV care within 6-12 months, 80-90% link
within 3-5 years
14. Retention in Care
3 population based studies in US found 45-
55% of known HIV+ individuals fail to receive
HIV care during any year
In some communities, one-third of HIV+
people fail to access care for 3 consecutive
years
~50% of HIV+ (aware) people are not engaged
in regular HIV care.
Poor engagement in care is associated with
poor health outcomes, including increased
mortality and increased risk of HIV
transmission
17. Antiretroviral Therapy
Gardner estimates that 80% of in-care HIV+
individuals should be receiving ART, but 25%
of those are not.
4-6% of in-care HIV+ people discontinue ART
each year
70-80% adherence leads to durable viral
suppression in most people
78-87% of individuals on ART had an
undetectable viral load.
19. Test and Treat Implications
Epidemiological data suggests that ART
reduces risk of HIV transmission in
serodiscordant heterosexual couples by 92-
98%
Ecological data show that incidence of HIV
transmission may be occurring in communities
with high treatment coverage (San Francisco)
20. Simulations of the Engagement in HIV Care Spectrum to
Account for Inaccuracy in our Engagement Estimates
1200000
Number of Individuals
Un-Diagnosed HIV
1000000
Not Linked to Care
800000
Not Retained in Care
600000 ART Not Required
400000 ART Not Utililzed
66%
Viremic on ART
200000 34% 28%
19% 22% 21% Undetectable Viral Load
0
Current Dx 90% Engage 90% Treat 90% VL<50 in 90% Dx, Engage,
Tx, and
VL<50 in 90%
(a) (b) (c) (d) (e) (f)
21. Newer Data for Discussion
Marks et al. estimated that 29 – 34% of HIV-
infected individuals in the U.S. have an
undetectable viral load (Clin Infect Dis 2011;53:1168–9)
Dombrowski et al. estimate that 42 – 45% in
Seattle King County are undetectable (AIDS
2011;epub ahead of print)
In a cohort of newly diagnosed individuals in
Denver, 28% are undetectable 12 – 18 months
after diagnosis.
22. Limitations
Unable to assess the impact of financial
barriers to HIV care in the U.S.
Overlap in the stages of engagement in HIV
care
Cross-sectional depiction of a longitudinal
process
The review applies to the U.S. and not to
resource-poor settings
23. Conclusions
Engagement in care is critical to the successful
management of HIV infection
For the individual
For the population
Deficiencies in the spectrum of engagement in
care present formidable barriers to „test and
treat‟ for HIV prevention:
Failure to diagnose
Failure to link to care
Failure to be retained in care
Failure to receive and adhere to antiretroviral therapy
Research is needed on ways to improve
transitions across all steps in the engagement
in care cascade
25. Undiagnosed HIV/AIDS - EMA
In EMA estimated 6,800 people are unaware
of their status
In Philadelphia- 25% concurrent HIV/AIDS in
2009 (a.k.a. “late testers”) – consumer survey
data supports this number
Most likely to be
African American/Hispanic
Male
Over 40
Heterosexual or unidentified risk
28. Linkage to Care
Surveillance data show that 73% of PLWHA in
Philadelphia are linked to care – 11,500
2010 Unmet EMA need estimate – 6,044
Philadelphia Unmet Need – 4,388
73% of PLWHA with unmet need are male
65% are African American/Black
Of those with unmet need - Medicaid (29%) and
unknown insurance status (25%)
29. Client Services Unit
10 weeks after initial intake – 78% in MCM
Linkage to Medical care within 10 weeks –
97% (includes people already in care at
intake)
26% had no insurance at intake
44% had Medicaid
30. Linkage to Care - Survey
74% of respondents got into care right away
85% within a year of diagnosis
Late testers slightly more likely to get into care
right away
4% got into care after they were sick
31. Retention
7719 Philadelphia PWHA retained in care
(HRSA definition)
93% of consumer survey respondents had a
regular place for HIV care
77% of respondents had 3 or more HIV care
visits in 12 months
95% of respondents had any # of visits in 12
months
32. ART and Adherence
38% of survey respondents had CD4 over 500.
33% between 200-500
11% under 200
13% did not know
90% of survey respondents on ART
97% of late testers
89% of HIV+
33. Viral Load
6,793 PLWHA on ART in Philadelphia
5,366 have suppressed viral load (79% of ART)
67% of survey respondents report
undetectable viral load
27% of undetectables were late testers
14% did not know viral load
34. Philadelphia Estimate for Stage of
Engagement in Care
25,000
19,691
20,000
15,753
15,000
11,500
10,000
7,719
6,793
5,366
5,000
-
HIV-infected HIV-diagnosed Linked to HIV Retained in On ART Supressed viral
(as of care HIV care load (<=200
12/31/09) copies/mL)
Source: AACO, Dr. Kathleen Brady
36. HRSA‟s Pros and Cons of Test and
Treat
Pro Con
Widespread effective ART may lower
Widespread testing and treatment has
large financial cost implications
community viral load
Many barriers to HIV testing remain
More people will benefit from treatment
Modeling studies are flawed
Evidence shows Test and Treat works
We may not be able to treat our way
The strategy would help mitigate health out of the epidemic
disparities
Demand for treatment exceeds supply
Risk reduction counseling can be included in Behavioral disinhibition/risk
HIV testing compensation would compromise any
Test and treat would help link and retain decrease in incidence
people in care Current testing system makes
Test and treat would present opportunities capturing acute infections difficult
for prevention with patients‟ partners Viral suppression may not be possible
for everyone
People would receive referrals to supportive
services earlier in disease course Widespread treatment is unsustainable
People could begin treatment earlier in Treatment initiation may take time.
disease course
Unknown long term toxicities
Stigma and discrimination continue to
STI screening, treatment, and sexual health exist
education would be facilitated
HRSA CARE ACTION, January 2012
37. Supporting Research
A meta analysis examined 11 cohorts of
serodiscordant heterosexual couples with the
HIV+ partner on ART and a VL<400 showed
NO transmissions (Attia, Egger, Muller, et
al., 2009)
HPTN 052 – HIV+ men and women who were
on ART had a 96% reduced risk of transmitting
the virus to sexual partners
38. Effectiveness of Test and Treat
Dodd, Garnett & Hallet, 2010
Impact of Test and Treat depends crucially on the
epidemiological context
In some situations less aggressive interventions
achieve the same results
Testing every year and following up with
immediate treatment is not necessarily the most
cost-efficient strategy
Test and Treat intervention that does not reach full
implementation or coverage could increase long-
term ART costs.
39. Early retention in care and VL
Mugavero, Amico, Westfall et al., 2012
Higher rates of early retention in HIV care are
associated with achieving viral load suppression
and lower cumulative viral load burden
63% of overall sample achieved viral load
suppression in less than a year after entry into
care
Insured people reached suppression faster
The more visits (less no shows) the more likely
the person was to have viral load suppression
Each clinic “no show” conveyed a 17% increased risk
of delayed viral load suppression
40. VL and Risk Behaviors
Kalichman, Cherry, Amaral, et al., 2010 (MSM)
Nonadherence to ART was associated with greater
number of sex partners and engaging in unprotected
and protected anal intercourse (not moderated by
substance use)
Belief that having an undetectable viral load leads to
lower infectiousness was associated with greater
numbers of partners, including nonpositive
partners, and less condom use
Men who had undetectable viral load and believed
having an undetectable viral load made them less
infectious were significantly more likely to have had
an STI recently.
Beliefs regarding viral load rather than viral load itself
influence behavior
Notes de l'éditeur
Synthesized all these data to develop cascade model;79% of HIV+ people are aware50% are not adequately engaged in care60% of HIV+ individuals are not receiving regular HIV care because of deficits in diagnosis, linkage to care, or retention in careOf the remaining 40%, ~80% require ART, 75% of whom receive it~80% of treated individuals have an undetectable viral load That’s just 19% of the HIV+ population in the USNot surprising that with >80% of the HIV+ population with detectable viral loads we have not seen a decrease in incidence
Current estimates 90% diagnosed, other % remain the same90% of HIV+ diagnosed are engaged in care90% in care receive ART90% of people on ART achieve viral suppressionAssumes 90% known HIV diagnosis, 90% engagement in care, 90% receipt of ART, 90% achievement of undetectable viral loadThis demonstrates that improvement in any one component does not have a significant effect on the number of people achieving viral load suppression. Success of Test and Treat relies on the success of each component, by overcoming multiple sequential barriers. If an individual cannot overcome a specific barrier, they cannot move on the continuum and reach undetectable status. Improvement in the entire continuum of care is required for Test and Treat to substantially increase the proportion of HIV+ people with undetectable viral loads. Even if we reach 90% for all measures, ~34% of HIV+ individuals will still have a detectable viral load.
HIV-infected number is estimate based on CDC estimate that 21% of HIV infected people do not know status. Number calculated by adding 21% to 15,753 of known HIV+.HIV-diagnosed, #linked and retained in care are from AACO surveillance dataOn ART and suppressed viral load #’s are estimated from Medical Monitoring Project data