Rapporteur session Prevention

1
Rapporteur session Prevention

• Marie Laga, Belgium
• Didier Ekouevi, Cote dIvoire
• Eliana Cledy, Brazil

2
SEXUAL TRANSMISSION Male circumcision reduces
riks of HIV acquisition

• RCT in South Africa among men 18-24y willing to
  be circumcised
• 1590 men in circumcision arm and 1538 men in
  control arm FU 24 months
• HIV incidence circumcision 51 or 2.2 /100 py
• HIV incidence control 18 or 0.7/100 py
• Protective effect 65 (40-80)

Auvert B et al
3
Public health implications of findings

• Results need to be confirmed by 2 other ongoing
  trials from Kenya and Uganda (early 2007)
• Importance of promoting MC only as Risk
  reduction component of comprehensive Prevention
  package
• Concern of desinhibition
• Steps to take to assure MC is conducted in safe
  conditions in clinical and traditional settings

4
Hormonal contraception does not increase risk of
HIV acquisition in women

• Earlier studies concern about increased risk
• Cohort study among 6000 HIV(-) women in 3 sites
  (Uganda, Zimbabwe, Thailand)
• FU for 24 months comparison users OC and DMPA
  vs no users
• No association between use of Oral contraception
  or DMPA injections and HIV acquisition

FHI study on hormonal contraceptives
5
Ongoing Prevention trials Sexual Transmission

• Male circumcision
• Diaphragm (results expected 2007)
• Second generation Microbicides buffergel,
  Pro2000,C31G, cellulose sulfate, Carraguard
• Oral Acyclovir prophylaxis
• Pre-exposure prophylaxis with Tenofovir daily
  oral use
• ART as prevention in discordant couples

6
Future prevention trials

• Third generation Micobicides containing ARV
• New cervical barriers
• Combination barriers-microbicides
• Lower viral load of Acute HIV infections?
• challenges diagnostic tools to detect
• short window period
• which popluations

7
PRevention of Mother to Child TransmissionNVP
resistance in Mothers

• Addition of 4 or 7 days Combivir (CBV) post
  partum to single dose NVP reduces the emergence
  of NNRTI resistance

Mc Intyre J et al
8
Clinical significance of NVP resistance for
subsequent treatment in mothers?

• Côte dIvoire ( MTCT-Plus and Ditrame Plus Group
  study ) No difference of immunological response
  in the two groups
• Thailand No difference of immunological response
  in the two groups, but poorer virological
  response at month 6 and month-18, when women
  exposed previously to sdNVP
• Is Tenofovir alternative for NVP for PMTCT?

9
Prevention of Mother to Child transmission

• 95 of children born to HIV() mothers live
  developing countries where coverage of PMTCT
  programs is still lt 10
• Acceptability of HIV test remains important
  bottleneck
• (Re)emphasis needed on
• Prevention of HIV in women
• FP services to prevent pregnancies in HIV
  () women

10
(No Transcript)
11
New waves of HIV epidemic

• Explosive outbreak among IDU in Eastern Europe
  and Central Asia
• Mainly young sexually active males
• Preceeded by outbreaks of Hepatits C
• Distincitve molecular features
• Inadequate health response
• Urgent need to implement effective strategies
• Hope ! More countries adopt harm reduction

12
ART decreases viral load in genital
secretions What will be impact on population level
Blood plasma and seminal plasma viral load
reductions after the initiation of antiretroviral
therapy for patients 1 (a) and 2 (b). Viral load
at each time point is given as copies/ml with a
variation of 0.5 log10.
Source Taylor S, et al. AIDS 2001 15 424-6.
13
Impact of ART on incidence of HIV

• The expected impact of ART treatment on
  prevention among MSM has not happened
• Reduction in per contact transmission
  probablities as a result of ART has been
  counterbalanced or overwelmed by increases in
  unsafe sex and STI

14
(No Transcript)
15
Factors that could positively influence HIV
prevention in adition to genital viral load
reduction

• ART provision breaks the cycle of despair, denial
  and fatalism
• Increases uptake of HIV tests
• ART provision reduces stigma and increases
  disclosure
• ART prolongs lives of parents, therefore making
  next generation less vulnerable

16
HIV Infection scenarios of the impact of ART in
South Africa
40
Scenario B
30
Scenario A
HIV prevalence ()
20
Scenario C
10
0
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008



Year

• Actual HIV prevalence rates in South
  African pregnant women
• ----- Projection scenarios.
• Scenario A No ART
• Scenario B ART without improvements in
  prevention, and
• Scenario C ART accompanied by improved
  prevention

Source Abdool Karim SS, Abdool Karim Q, Baxter
C. Lancet 2003 362 1499.
17
Factors contributing to a possbile increase in
HIV transmission

• Increasing rate of unsafe safe
• Decreased fear of transmitting among HIV()
  people taking ART
• Community perception that HIV has become less
  transmissible and no longer deadly
• Increase in STI which are co-factors in HIV
  transmission

18
ARV roll out unlikely to reduce HIV incidence in
short term

• Treatment makes prevention easier and offers many
  new opportunities
• But treatment centered approach will not
  automatically result in Prevention benefits
• Specific attention should be paid to
  simultanously enhance prevention efforts in the
  health care setting and the wider community

19
From treatment activism to activism for
prevention and treatment