Marrazzo et al, JAMA , 2014.

1. HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International IAS-USA-Society Panel Jeanne M. Marrazzo, MD, MPH; Carlos del Rio, MD; David R. Holtgrave, PhD; Myron S. Cohen, MD; Seth C. Kalichman, PhD; Kenneth H. Mayer, MD; Julio S. G. Montaner, MD; Darrell P. Wheeler, PhD, MPH; Robert M. Grant, MD, MPH; Beatriz Grinsztejn, MD, PhD; N. Kumarasamy, MD, PhD; Steven Shoptaw, PhD; Rochelle P. Walensky, MD, MPH; François Dabis, MD, PhD; Jeremy Sugarman, MD, MPH; Constance A. Benson, MD Marrazzo et al, JAMA, 2014.

2. HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International Antiviral Society-USA Panel Free web access to the paper at jama.com

3. IAS-USA HIV Prevention Recommendations: Goal • Worldwide, ~2.3 million new HIV infections in 2012 • In US, ~50,000 new HIV infections each year—largely unchanged since the 1990s • Integrated biomedical and behavioral HIV prevention tools and ART for treatment offer chance to curb the HIV epidemic • Clinicians play a crucial role in implementing combination HIV prevention interventions • These recommendations seek to consolidate best practices for clinicians across a range of HIV prevention issues Marrazzo et al, JAMA, 2014.

4. IAS-USA HIV Prevention Recommendations: Process In 2013, international panel of HIV experts assembled by IAS-USA to develop evidence-based recommendations that integrate biomedical and behavioral interventions for HIV prevention in the clinical care setting IAS-USA, a 501(c)(3) not for profit organization that sponsors CME for physicians and medical practitioners involved in the care of people with HIV, HCV, or other viral infections, sponsored and provided all funding for the recommendations Volunteer panel members worked in teams to review and summarize scientific evidence and propose recommendations Final recommendations approved by panel consensus; ratings assigned based on strength of recommendation and quality of evidence

5. IAS-USA HIV Prevention Recommendations: Panel Cochairs Jeanne M. Marrazzo, MD, MPH University of Washington Carlos del Rio, MD Emory University David R. Holtgrave, PhD The Johns Hopkins Bloomberg School of Public Health Members Myron S. Cohen, MD University of North Carolina Seth C. Kalichman, PhD University of Connecticut Kenneth H. Mayer, MD Harvard Medical School Julio S. G. Montaner, MD University of British Columbia Darrell P. Wheeler, PhD, MPH Loyola University Chicago Robert M. Grant, MD, MPH University of California San Francisco Beatriz Grinsztejn, MD, PhD EvandroChagas Clinical Research Institute (IPEC)–FIOCRUZ N. Kumarasamy, MD, PhD YR Gaitonde Centre for AIDS Research and Education Steven Shoptaw, PhD University of California Los Angeles Rochelle P. Walensky, MD, MPH Massachusetts General Hospital François Dabis, MD, PhD Université de Bordeaux Jeremy Sugarman, MD, MPH The Johns Hopkins University Constance A. Benson, MD University of California San Diego Margaret A. Fischl, MD University of Miami

6. IAS-USA HIV Prevention Recommendations: Rating System Adapted in part from Canadian Task Force on the Periodic Health Examination, Can Med Assoc J,1979

7. IAS-USA HIV Prevention Recommendations: Sections HIV Testing and Knowledge of Serostatus Prevention Measures for HIV-Infected Individuals Prevention Measures for HIV-Uninfected Individuals Prevention Issues Relevant to All Persons With or At Risk for HIV Infection Marrazzo et al, JAMA, 2014.

8. HIV Testing and Knowledge of Serostatus Marrazzo et al, JAMA, 2014.

9. HIV Testing and Knowledge of Serostatus Marrazzo et al, JAMA, 2014.

10. HIV Testing and Knowledge of Serostatus(cont’d) Marrazzo et al, JAMA, 2014.

11. HIV Testing and Knowledge of Serostatus(cont’d) Marrazzo et al, JAMA, 2014.

12. Prevention Measures for HIV-Infected Individuals Marrazzo et al, JAMA, 2014.

13. Antiretroviral Therapy Marrazzo et al, JAMA, 2014.

14. Counseling on Risk Reduction, Disclosure of HIV Serostatus, and Partner Notification Marrazzo et al, JAMA, 2014.

15. Needle Exchange and Other Harm Reduction Interventions Marrazzo et al, JAMA, 2014.

16. Strategies for Promoting Movement Through the Continuum of HIV Care Marrazzo et al, JAMA, 2014.

17. Risk Assessment and Risk Reduction for HIV Infection Marrazzo et al, JAMA, 2014.

18. Prevention Measures for HIV-Uninfected Individuals Marrazzo et al, JAMA, 2014.

19. Efficacy of Biomedical Interventions to Prevent HIV Acquisition: Summary of the Evidence from Randomized Clinical Trials Modified from Ambitious Treatment Targets: Writing the Final Chapterof the AIDS Epidemic, UNAIDS, 2014.

20. Preexposure Prophylaxis (PrEP) Marrazzo et al, JAMA, 2014.

21. PreexposureProphylaxis (cont’d) Marrazzo et al, JAMA, 2014.

22. Preexposure Prophylaxis (cont’d) Marrazzo et al, JAMA, 2014.

23. Postexposure Prophylaxis (PEP) Marrazzo et al, JAMA, 2014.

24. Voluntary Medical Male Circumcision Marrazzo et al, JAMA, 2014.

25. Prevention Measures for All Individuals With or at Risk for HIV Infection Marrazzo et al, JAMA, 2014.

26. Screening and Treatment for STIs Marrazzo et al, JAMA, 2014.

27. Screening and Treatment for STIs(cont’d) Marrazzo et al, JAMA, 2014.

28. Reproductive Health Care/Hormonal Contraception Marrazzo et al, JAMA, 2014.

29. Summary • After 30 years, an AIDS-free generation could be a reality • Clinicians’ efforts are needed to: • Offer all adults and adolescents HIV testing For all persons with, or at risk for, HIV: • Regularly assess substance use and sexual risk practices • Offer ART and adherence support at diagnosis of HIV; PrEP and adherence support to those at risk • Have a high index of suspicion for nonspecific presentation of symptomatic acute HIV infection • Emphasize and support linkage to care • Facilitate individualized risk-reduction counseling • Conduct regular STI screening Marrazzo et al, JAMA, 2014.

30. Trends in Annual Age-Adjusted* Rate of Death Due to HIV Infection, United States, 1987−2010 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules. *Standard: age distribution of 2000 US population

35. HIV Continuum of Care General population: 9.2% engaging in risk behaviors HIV-positive: 1,144,500 Diagnosed with HIV: 963,600 Diagnosed with HIV in 2011: 79.8% linked to care Diagnosed with HIV as of 2010: 50.9% retained in care Diagnosed with HIV as of 2010: 327,485 with viral load <200 copies/ml ~50K new infections per year 28.6% virologically suppressed Source: CDC, 2013 and Holtgrave et al, 2012

36. HIV Continuum of Care Approx 1.1 million with HIV in US Source: CDC, http://aids.gov/federal-resources/policies/care-continuum/.

37. The Need for HIV Prevention: Continued HIV Risk in the US • Estimated new HIV infections in the United States for the most affected subpopulations, 2008-2011 70 60 Male-to-male sexual contact Heterosexual contact IDU Male-to-male sexual contact and IDUOther 50 40 Diagnoses (%) 30 20 10 0 2008 2009 2010 2011 Yr CDC. HIV in the United States: 2013.

38. Rationale for Routine HIV Screening:Initial CD4 Cell Count (NA-ACCORD) Althoff KN, et al. Clin Infect Dis. 2010;50:1512-20.

39. Median CD4+ cell count after Starting HAART (by baseline CD4+ category) Rationale for Routine HIV Screening:Initial CD4 and Response to HAART • Palella FJ, et al. 2010 CROI. Abstract 983. > 500 350-499 200-349 50-199 < 50

40. Median CD4+ cell count after Starting HAART (by baseline CD4+ category) Rationale for Routine HIV Screening:Initial CD4 and Response to HAART • Palella FJ, et al. 2010 CROI. Abstract 983. > 500 350-499 200-349 50-199 < 50

41. Marks et al. AIDS, 2006 Earlier Diagnosis Has Benefits: Ignorance is Not Bliss New infections Living with HIV: 1.1M ~21% unaware 54-70% Transmission 30-46% ~79% aware Marks et al. AIDS, 2006

42. IASUSA Antiretroviral Guidelines 1996 – 2014 Günthard et al, JAMA, 2014.