STOP HIV – TB: Special Populations, The Vancouver Experience

Rolando Barrios, MDAssistant Director

BC Centre for Excellence in HIV/AIDSSenior Medical Director

Vancouver Community Health Services, Vancouver Coastal HealthAdjunct Professor

School of Population and Public Health, UBC

PresenterPresentation NotesHuānying

Outline

• Overview of TB & HIV in British Columbia (BC) & Vancouver

• Vancouver: Treatment as Prevention• Special Populations: IVU• STOP HIV/AIDS – Pilot Project in BC• Lessons and Challenges

British Columbia, Canadá

British Columbia:Localizada en el Pacifico~3.5 Millones de habitantesCiudades Principales:Vancouver, Victoria, Prince George

Canadá: 10 Provincias y 4 Territorios

~ 35 Millones de habitantes

Segundo país mas grande del mundo.

VancouverUrban centre with Inner City challenges

Highest and lowest BC socio-economic status in one geographic area

HIVLow prevalence epidemic

~15,000 infected with HIV in BC (1)26% are unaware of their HIV status (2)

~ 6,000 on ART (1)~ 3,500 in need of ART not on ART (1)~ 300 new HIV cases per year (3)

Micro epidemics

Inequities in outcomes

(1) Hogg RS. Drug Treatment Program, BCCFE(2) Health Canada 2009(3) HIV Surveillance, BCCDC. 2010

(1) CHASE final report, VCHA, May 2005(2) Tyndall, Mark et al. “HIV seroprevalence among participants at a Supervised Injection Facility in Vancouver, Canada: implications for prevention, care and Treatment” Harm Reduction Journal 2006, 3:36

Population: 16,000Drug addictionMental Health illnessViolence

HIV Prevalence~18% (1)Higher among aboriginals (28%) (2)

Vancouver’s Downtown Eastside

Inequities in outcomes

• Higher HIV-related mortality in:–Aboriginal populations–Vancouver’s Downtown Eastside–Prince George

HIV in Aboriginal People

Eric Druyts, et al. BC-CfE, CAHR, 2009

DTES

BC

HA1a vs 1b

0

20

40

60

80

100

120

140

160

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

year

Vancouver Total (joinpoint) City Centre (joinpoint) Downtown Eastside (joinpoint)Vancouver Total (observed) City Centre (observed) Downtown Eastside (observed)

HIV-related Mortality in BC

TB Active Cases -2008

Tuberculosis incidence rates in sub-Vancouver areas, 2005 - 2008

HIV status of TB cases in BC

The percentage of TB patients tested for HIV infection has steadily increased from 42% (2005) to 62% (2008)

The percentage of HIV patients tested for TB varies from site to site from 40 – 80%

TB status of HIV cases in BC

Vancouver?

Vancouver 1996“One World One Hope”

J Mellors et al. Annals 1997

0

20

40

60

80

100> 750501-750351-500201-350< 200

> 30 10-30 3-10 0.5-3 < 0.5

CD4+ cells/µL

Plasma HIV RNA (thousand copies/mL)

% Progression to AIDS in 3 yrs

Vancouver 1996“One World One Hope”

Plasma Viral Load, a strong Predictor of outcome in HIV Infected IndividualsHigh Plasma Viral Load: Poor PrognosisLow Plasma Viral Load: Good Prognosis

Montaner et al JAMA, March 25th 1998

Triple Therapy: AZT + ddI + NVP

AZT + ddI

AZT + NVP

Study Weeks0

0

-1

-2

-3

Dual Therapy Regimens

Triple Therapy: AZT+3TC+IDV

Gulick et al; JAMA, July 1, 1998

52

ART stops HIV replication

↓

HIV load falls to undetectable levels in plasma

as well as in sexual fluids↓

Sharp reduction in HIV transmission

Expanding HAART Coverage in BC within the evolving IAS-USA Therapeutic Guidelines

90

80

70

60

Inci

denc

e/yr

Vira

l loa

d<

50/m

L (%

)

Acquired resistancefalling

Plasma viral load suppression rising

BC-CDC Report, 2009

Number of HIV tests per Year in BC

1994 2000 2008

Hepatitis C, 1999-2008 Infectious Syphilis, 1999-2008

Genital Chlamydia, 1999-2008 Gonorrhea, 1999-2008

• BC

x Canada

• BC

x Canada

• BC

x Canada• BC

x Canada

2004

2004 2004

2004

Community Viral Load and New HIV

Cases in SFco

Das M, Chu PL, Santos G-M, Scheer S, Vittinghoff E, et al.

Decreases in Community Viral Load Are Accompanied by Reductions in New HIV

Infections in San Francisco. PLoS ONE 2010 5(6): e11068.

doi:10.1371/journal.pone.0011068

n=12,512 unduplicated HIV-positive individuals.

HPTN 052 (www.hptn.org)• HIV discordant couples (n=1750)

• India, Brazil, Thailand, Malawi, Zimbabwe

• BSL CD4 count 250 to 500/mm3

• Index Patient randomized to

- HAART vs

- SoC: HAART after 200/mm3 latter amended to 250/mm3

M Cohen et al, NIH Press Conference May 12th 2011. To be presented at IAS-Rome, July 2011

HPTN 052 (www.hptn.org) Seroconversions (genetically linked)

Deferred HAART: 27 cases (>1%)

Immediate HAART: 1 case (0.1%)

HR = 0.37 or 96.3% reduction in transmission

No diff whether index pt was M or F

Overall Morbidity and Mortality Deferred HAART: 60 cases

Immediate HAART: 40 cases

Extra-Pulmonary TB Deferred HAART: 17 cases

Immediate HAART: 3 cases

M Cohen et al, NIH Press Conference May 12th 2011. To be presented at IAS-Rome, July 2011

Impact of HAART on IDUs

Wood et al, BMJ, 2009

Whiskers represent 95% confidence intervals.

HAART Reduces HIV incidence in IDUs

G Kirk, …, D Vlahov for the Alive Cohort, CROI 2011

Youth

Adults

PreventionWithdrawal

Management Treatment

Housing

Access into Health Care

SupportRecovery

HarmReduction

Insite

Access Central

Life Skills Centre

Home/Outpatient Detox

Adult Daytox

Short Term Residential Social Detox

Short Term Residential Medical Detox

OnSite

Rainier Women’s Treatment Program

Tobacco Dependency Program

Support Recovery Programs

Community Health Centres

Day Treatment

Clinical Housing Team

Clinical Tenant Support Team

Clinical Outreach Team

CTCT

VAMP

CDRT

Housing First

Alcohol and Drug Free Housing

Supported Housing

Pennsylvania Suites

Home Detox

Residential Detox

Peak House

Health Promotion & Education

Early Intervention

School -aged based Prevention (SACY)

Prevention Workers (CHC)

A&D CounsellingDrop-ins

Odyssey II

Watari

Support Recovery Programs

Watari

1 to 1 Counselling

Day Treatment & Community Services

Residential Treatment Beds

Addiction Services

Youth SILs

Health Promotion & Education

Early Intervention

Education

Needle Exchange

Community Patrols

Sobering

Safe Ride

Peer to Peer

VANDU

Consumers Board

Sheway

Education

Needle Exchange

Community Patrols

Sobering

Safe Ride

Peer to Peer

VANDU

Consumers Board

Summary of Findings to Date Reductions in public disorder

(Wood et al., Canadian Medical Association Journal, 2004, Petrar et al., Addictive Behaviors, Stoltz et al., Journal of Public Health, 2007)

Reductions in syringe sharing(Kerr et al., The Lancet, 2005, Wood et al., American Journal of Infectious Diseases, 2005)

Successful management of over 1000 overdoses(Kerr et al., IJDP, 2006, Kerr et al., IJDP, 2007)

Increased use of detox programs and addiction treatment (Wood et al., New England Journal of Medicine, 2006, Wood et al., Addiction, 2007, DeBeck et al., Drug and Alcohol Dependence, 2010)

Reductions in violence against women(Fairbairn et al, 2008, Social Science and Medicine)

Increases in condom use(Marshall et al, 2008)

Summary (cont…) Overdose deaths averted

(Milloy et al, PLOS One, 2008, Marshall et al, Lancet 2011)

No adverse changes in community drug use patterns(Kerr et al., British Medical Journal, 2006)

No increases in initiation into injection drug use(Kerr et al., American Journal of Public Health, 2007)

No increases in drug-related crime(Wood et al., Substance Abuse Treatment. Prevention, and Policy, 2006)

Insite is cost-effective(Bayoumi & Zaric, CMAJ, 2008, Andersen & Boyd, IJDP, 2010, Pinkerton, Addiction, 2010)

STOP HIV/AIDS: Seek and Treat for Optimal Prevention

of HIV/AIDS

STOP HIV/AIDS• Seek Unaware of their HIV Diagnosis Re-engagement of those “lost to care”

Treat & Retain Ensure prompt linkage to care Ongoing Monitoring and Prompt initiation of HAART as

per clinical guidelines Support to retain in care and optimize adherence

Evaluate Outcomes Impact

ULTIMATE GOAL:

• Treat those who need treatment Reduce HIV-related morbidity and mortality

• Decrease HIV incidence Cost-averting

CONTINUUM OF HIV CARE

Identify case

Identify contacts

Diagnose Disease

Clinical Assessment

On going Clinical Monitoring

Initiation of HAART

Optimal HAART adherence Sustained Viral

suppression

Barrios, Day, Hogg, Montaner - Unpublished

PopulationsAt risk

MorbidityMortality

Improved Outcomes

NO

YES

Model for Monitoring & Evaluating STOP HIV/AIDSPopulationsAt risk

Identify contacts

Diagnose Disease

Clinical Assessment

Clinical Monitoring

Initiation of HAART

Optimal HAART adherence

Sustained Viral suppression

Reduce HIV Incidence

Reduce HIV related Morbidity & Mortality

Barrios, Day, Hogg, Montaner - Unpublished

Identify case

Case finding

Contact tracing

Linkage to care

Retention in care

Outcomes

Outcomes

Impr

oved

pop

ulat

ion

heal

th s

tatu

s

Impa

ct

Current initiatives: Testing

• Testing initiatives underwayProvider initiated testingTargeted testingPoint of care testing

Current initiatives: Treatment

• Developing Standards of Care• Scaling up harm reduction

interventions• HIV Quality Improvement initiative• Training and education of primary

care providers

Lessons learned

• Stop “planning the plan”• Persistence• Create awareness• Target key government officials

– Good for the individual– Good for the public– Good for the pocket

• Gain community/media support

Challenges

• Providers - main barrier for increasing HIV testing

• Significant paradigm shift• Bureaucracy takes time – process oriented• Harm reduction – Debate ideology vs

Science

Thank you!

British Columbia Centre for Excellence in HIV/AIDS

rbarrios@cfenet.ubc.ca

STOP HIV – TB: Special Populations, �The Vancouver ExperienceOutlineSlide Number 3VancouverSlide Number 5Slide Number 6Inequities in outcomesHIV in Aboriginal PeopleHIV-related Mortality in BCSlide Number 10Slide Number 11Slide Number 12Vancouver?Vancouver 1996�“One World One Hope”Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Community Viral Load and New HIV Cases in SFcoHPTN 052 (www.hptn.org)HPTN 052 (www.hptn.org)Impact of HAART on IDUsSlide Number 29HAART Reduces HIV incidence in IDUsAddiction ServicesSlide Number 32Slide Number 33Summary of Findings to DateSummary (cont…)STOP HIV/AIDS: Seek and Treat for Optimal Prevention of HIV/AIDSSlide Number 37STOP HIV/AIDSULTIMATE GOAL:CONTINUUM OF HIV CAREModel for Monitoring & Evaluating STOP HIV/AIDSCurrent initiatives: TestingCurrent initiatives: TreatmentLessons learnedChallengesSlide Number 46