TasP is not enough Stipulated that TasP is effective in reducing infectiousness of the treated person – But much more is required. TasP requires effective behavioral interventions – Testing, access, linkage, retention, adherence – Processes that occur outside of the clinic Prevention requires a diverse portfolio of services so that there is something attractive for everyone. – Many prevention services are more cost effective than TasP Social benefits are Important

CDC Cascade MMWR December 2, 2011 / 60(47);

SF DPH, Annual Report, 2011

Nicole Johns on 20 November 2012, Philadelphia EMA Ryan White Part A Planning Council and HIV Prevention Group.

Nicole Johns on 20 November 2012, the Philadelphia EMA Ryan White Part A Planning Council and the Philadelphia HIV Prevention Group.

Figure 2. Estimated trends in HIV incidence and sexual behaviour. Phillips AN, Cambiano V, Nakagawa F, Brown AE, et al. (2013) Increased HIV Incidence in Men Who Have Sex with Men Despite High Levels of ART-Induced Viral Suppression: Analysis of an Extensively Documented Epidemic. PLoS ONE 8(2): e doi: /journal.pone

Why is TasP not working? Requires engagement, testing, linkage, adherence. – Processes occur outside of clinics and clinical thinking. – Only 28% with HIV in the US are effectively treated. – Only 44% in San Francisco (a privileged setting). Risk compensation In couples, a third of infections arise from outside the primary partnership. 10 to 50% of new infections come from acute infections, before they can be diagnosed and treated.

The Prevention Portfolio is Diverse: HIV Testing and counseling Condoms Circumcision Needle Exchange Interactive client based counseling – For adherence, for harm reduction Treatment for Positives PREP for Negatives Listen to what people want

Nothing passes through condoms: Use with confidence

Learning From Prior Success Condom Use in Early 1980s “Love Carefully” Uganda 1990s Seroadaptive Behaviors Late 1990s Common Characteristics – Grass Roots Initiatives – Focus on immediate concerns – Motivated by Sexual and Social Goals

Risk Reduction During PREP Use By Drug Concentration Drug Concentration Comensurate with Doses HIV Risk Reduction* 95% Confidence Interval 2 per week76%56% to 96% 4 per week96%90% to >99% 7 per week99%96% to >99% Anderson et al, Science Translational Medicine :151ra125 *Compared with placebo, after controlling for numbers of partners, condom use, STIs, age, site

Adequate Adherence to PREP is Feasible Drug Detection* Region (%) 94%43% USANon USA Time Points Median TFV-DP Level 2619 P < *Detection of TFV/FTC/TFV-DP or FTC-TP in plasma or PBMC

Figure 2. Comparison of PrEP versus earlier ART initiation for keeping couples “ alive and HIV free at 50. ” Hallett TB, Baeten JM, Heffron R, Barnabas R, et al. (2011) Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modelling Study. PLoS Med 8(11): e doi: /journal.pmed

Ways PrEP Could Enable Treatment Decreased burden on HIV treatment programs, Motivates HIV testing, – Provides benefits to people hoping they are uninfected, – Seropositives may be linked into care. More timely identification of acute infections, – Allows earlier therapy initiation, – Enables cure research for acute infection. Greater familiarity with antiretroviral therapy, – A diversity of providers serving a diversity of people, – Uninfected people become aware of therapy and HIV. May destigmatize therapy and the people who use it.

Social Benefits 18 TasPOther Prevention Less HIV Transmission Decreased (non- pulmonary) TB Disease Prevention other STI transmission Social empowerment of women, youth, LGBT communities, communities of color; housing, jobs, food; family planning.

Combination Prevention

A Combination of Approaches is Essential for Increasing Uptake and Use of Prevention Methods to Levels Required to End AIDS 20