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Kristin M. Wall , PhD kmwall@emory Department of Epidemiology

From efficacy to effectiveness: HIV seroincidence by ART status among HIV discordant couples in Zambia. Kristin M. Wall , PhD kmwall@emory.edu Department of Epidemiology Rwanda Zambia HIV Research Group Emory University, Atlanta, GA, USA. Conflict of Interest Disclosure.

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Kristin M. Wall , PhD kmwall@emory Department of Epidemiology

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  1. From efficacy to effectiveness: HIV seroincidence by ART status among HIV discordant couples in Zambia Kristin M. Wall, PhD kmwall@emory.edu Department of Epidemiology Rwanda Zambia HIV Research Group Emory University, Atlanta, GA, USA

  2. Conflict of Interest Disclosure The authors have no conflicts of interest due to financial or personal relationships that might be perceived to cause bias.

  3. Acronyms for this talk TasP:Antiretroviral treatment (ART)-as-prevention • For the purposes of this talk, ART has been provided for therapeutic reasons only CVCT: Couples’ voluntary HIV counseling and testing • Joint pre-test counseling • Rapid HIV testing • Joint post-test counseling

  4. CVCT: transmission in serodiscordant couples by 2/3 • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992) • TasP: 96% efficacy in serodiscordant couples • (Cohen et al, NEJM, 2011)

  5. CVCT: transmission in serodiscordant couples by 2/3 • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992) • TasP: 96% efficacy in serodiscordant couples • (Cohen et al, NEJM, 2011) CVCT WHO, 2012 (Recs 1-3) TasP WHO, 2012 (Recs 5)

  6. CVCT: transmission in serodiscordant couples by 2/3 • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992) • TasP: 96% efficacy in serodiscordant couples • (Cohen et al, NEJM, 2011) CVCT WHO, 2012 (Recs 1-3) TasP WHO, 2012 (Recs 5) CVCT: WHO Recs 1-3 TasP: WHO Rec 5 (WHO, 2012) • Real-world TasPeffectiveness in discordant couples?

  7. CVCT: transmission in serodiscordant couples by 2/3 • (Allen et al, JAMA, 1992; Allen et al, BMJ, 1992) • TasP: 96% efficacy in serodiscordant couples • (Cohen et al, NEJM, 2011) CVCT WHO, 2012 (Recs 1-3) TasP WHO, 2012 (Recs 5) ART adherence? ARV resistance? • Real-world TasPeffectiveness in discordant couples?

  8. CVCT scale-up in government clinics HIV prevalence, 15-49 year olds (DHS)

  9. Impact of CVCT on HIV transmission in a real-world setting 82% reduction in transmission after CVCT RR 0.2 (95% CI 0.1-0.4) Cost of preventing one HIV infection with CVCT in Zambia $392 69% reduction in transmission after CVCT RR 0.3 (95% CI 0.2-0.6)

  10. Impact of CVCT on HIV transmission in a real-world setting 82% reduction in transmission after CVCT RR 0.2 (95% CI 0.1-0.4)

  11. Teasing apart the effects of CVCT and TasP 73% reduction in transmission after CVCT RR 0.3 (0.1-0.6) $666 to prevent one HIV infection 83% reduction in transmission after CVCT RR 0.2 (95% CI 0.1-0.4)

  12. Conclusions CVCT is effective in a real-world setting • Irrespective of preceding therapeutic ART use • 70-80% reduction in HIV incidence, $400-$700 per infection averted TasP is not as effective in real-world settings as in a trial among serodiscordant couples who: • Have NOT been tested and counseled together • 30% reduction among those on therapeutic ART

  13. Future Questions: ART Adherence? How much can retention and adherence improve when ART patients are counseled with their HIV- spouses? • ART NON-adherence: 40%1-2 • ART attrition at 1 year: ¼3-4 1. Sasaki et al, An ClinMicAntimicro, 2012; 2. Birbeck, AJTMH 2009; 3. Scott et al, BMC Pub Health 2014; 4. Fox et al, TMIH, 2010

  14. Future Questions: ARV Resistance? Were ARV resistant viruses transmitted? • ARV resistance:1-2 • 5-6% of ART naïve 1. Price et al 2011; 2; Hamerset al, JAIDS, 2010 http://hivdb.stanford.edu/surveillance/map/

  15. Recommendations CVCT should be promoted and provided in all settings that offer HIV testing (WHO 2012 Recommendations 1-3 of Couples’ HIV Counseling Guidelines), including: • Antenatal clinics • PITC • Community-based VCT • Household VCT CVCT should be a priority in ART clinics(WHO 2012 Recommendation 4 of Couples’ HIV Counseling Guidelines) Resource allocation models should include CVCT and TasP • Using real-world estimates of effectiveness

  16. Acknowledgements Rwanda Zambia HIV Research Group (RZHRG) Contributors Mubiana Inambao M. KakunguSimpungwe Rachel Parker Joseph Abdallah Nuri Ahmed William Kilembe Amanda Tichacek ElwynChomba Gordon Streeb Susan Allen Arise—Enhancing HIV Prevention Programs for At-Risk Populations IbouThior Julie Pulerwitz Zambian Ministry of Health & District Health Management Team CVCT Clients & Clinic Staff

  17. Support for this project was provided by the Canadian Government through PATH and the Department of Foreign Affairs Trade and Development. The views expressed by the authors do not necessarily reflect the views of PATH, the Canadian Government or the Department of Foreign Affairs Trade and Development. This document was produced under Arise—Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. Arise implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.

  18. Other RZHRG posters/presentations supported by PATH-Arise Arise Satellite Session, Thursday July 24th, 18:30-20:30 in Plenary 3 Posters • TUPE167 • TUPE368 • WEPE 435 • WEPE 206 Oral poster • THAC0504 Oral abstract • THPDE0104

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