TRACK C RAPPORTEURS REPORT

Prepared by Anne BuvéBelgium Anne BuvéBelgium Sabina Bindra-BarnesIndia Sabina Bindra-BarnesIndia Saidi KapigaTanzania Saidi KapigaTanzania Jorge SanchèzPeru Jorge SanchèzPeru David WilsonAustralia David WilsonAustralia

The CAPRISA 004 trial Trial of vaginal microbicide: 1% Tenofovir gel in HIV negative women in South Africa Trial of vaginal microbicide: 1% Tenofovir gel in HIV negative women in South Africa Proof of concept trial, double-blind, placebo-controlled Proof of concept trial, double-blind, placebo-controlled Coital dependent insertion of gel Coital dependent insertion of gel

The CAPRISA 004 trial TenofovirPlacebo HIV incidence IRR = 0.61 (0.4 – 0.94) Protective effect 39% (6 – 60) HSV-2 incidence IRR = 0.49 (0.3 – 0.78) Protective effect 51% (22 – 70)

The CAPRISA 004 trial No safety issues, no resistance detected No safety issues, no resistance detected Excited, but not ready for roll out Excited, but not ready for roll out –One trial in one population –Adherence: can we do better?

Young people Trends in HIV and behaviors in young people yrs (TuAC0204) Trends in HIV and behaviors in young people yrs (TuAC0204) 21 countries with generalised epidemics (Africa and the Caribbean) 21 countries with generalised epidemics (Africa and the Caribbean) 2000 – 2008: 2000 – 2008: –significant reduction of 25% in HIV prevalence in 10 countries –correlation with behavior change in 8

Incentivising behavior change? Malawi: Zomba cash transfer program (SUSA22) Malawi: Zomba cash transfer program (SUSA22) Cash transfers to schoolgirls and young women who had recently dropped out of school to stay in (or return to) school After 1 year, among school girls After 1 year, among school girls Significantly lower prevalence of HIV and HSV-2 in the intervention group than the control group (but no baseline data) Effect due to schooling or higher income? Effect due to schooling or higher income?

Intravenous drug users RDS survey in 8 cities in Russia ( ) RDS survey in 8 cities in Russia ( ) –HIV: 2.6 % % (>50% in 3 cities) –HCV prevalence: 49% - 90% –Non-IDU sexual partners: 32% - 70% MOAC0202 Zanzibar (2007): first RDS survey among IDU in Africa Zanzibar (2007): first RDS survey among IDU in Africa –HIV: 16%,associated with high risk sexual behavior MOAC0401

Needle and syringe programmes NSPs in Australia (MOAC0403) NSPs in Australia (MOAC0403) –In the past 10 years, for every 1$ invested in NSPs 0.2 days of disability adjusted life saved 0.2 days of disability adjusted life saved > 4$ returned in health care cost savings > 4$ returned in health care cost savings

Needle and syringe programmes NSPs in Estonia (MOAC0402) NSPs in Estonia (MOAC0402) –2003 – 2009: numbers of needles distributed from 18,000 to >770,000 – : HIV incidence among new injectors (start injecting < 5 yrs ago) 18 / 100 pyrs to 7.5 / 100 pyrs Strong evidence on cost-effectiveness but policies and laws block implementation (Lancet series). Strong evidence on cost-effectiveness but policies and laws block implementation (Lancet series).

MSM Survey in Kampala (Uganda) – RDS Survey in Kampala (Uganda) – RDS –HIV: 14% –Recruitment difficult because of police actions Opening session:”Human rights violations are a barrier to knowing your epidemic” (TUAC0305)

MSM South Africa and Senegal: difficult access to prevention and care services (WEPDC101 & WEPDC102) South Africa and Senegal: difficult access to prevention and care services (WEPDC101 & WEPDC102) Lack of understanding of risk behaviors by service providers - risky behaviors with female partners.

Commercial sex workers Avahan: program targeting sex workers in 6 states in India – worldwide largest SW program Avahan: program targeting sex workers in 6 states in India – worldwide largest SW program Karnataka: baseline survey and follow-up survey Karnataka: baseline survey and follow-up survey –Longer duration of program exposure associated with increased condom use –Significant reduction in HIV: 19.6% to 16.4%

Male circumcision: where are we? Kenya: rapid scale up was feasible and safe – task shifting Kenya: rapid scale up was feasible and safe – task shifting Kisumu (Kenya): population based survey Kisumu (Kenya): population based survey –Increase in prevalence of MC –No evidence of sexual risk compensation. (THAC0103 & THAC0101)

Mother-to-child transmission Coverage of PMTCT in Eastern and Southern Africa: 58% (THSY09) Coverage of PMTCT in Eastern and Southern Africa: 58% (THSY09) The Antiretroviral Pregnancy Registry: The Antiretroviral Pregnancy Registry: –Overall prevalence of birth defects for any ART exposure during pregnancy: 2.7 per 100 live births (session WEAX01)

Treatment as prevention Biological plausibility Biological plausibility Mathematical models Mathematical models Empirical evidence Empirical evidence –Individual level: discordant couples Risk of transmission very low but not 0 –Population level: ecological analyses, e.g. British Columbia, Denmark (MOAC0103)

Treatment as prevention Issues (WESY0705) Issues (WESY0705) –Transmission during acute infection: how much? –Transmission of resistant strains –Sustainability of viral suppression: how long?

Combination prevention “The strategic, simultaneous use of different classes of prevention activities (biomedical, behavioral, social/ structural) that operate on multiple levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritizing, partnership and engagement of affected communities”. “The strategic, simultaneous use of different classes of prevention activities (biomedical, behavioral, social/ structural) that operate on multiple levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritizing, partnership and engagement of affected communities”.

Combination prevention Challenging to evaluate Challenging to evaluate –RCTs difficult, may not be suited –Use of variety of methods and data sources –Make pathway to impact explicit