AIDS 2012 Where are we, and where are we going? Mitchell Warren Executive Director, AVAC August 15, 2012

“Few could have imagined that we’d be talking about the real possibility of an AIDS-free generation. But that’s what we’re talking about.”

Study Effect size (CI) Medical male circumcision (Orange Farm, 2005; Rakai, Kisumu, 2007) 57% (42, 68) Prime-boost Vaccine (Thai RV144, 2009 ) 31% (1, 51) Efficacy 0% % What Works in HIV prevention, 6/10

Study Effect size (CI) Medical male circumcision (Orange Farm, 2005; Rakai, Kisumu, 2007) 57% (42, 68) Prime-boost Vaccine (Thai RV144, 2009 ) 31% (1, 51) Efficacy 0% % TDF/FTC oral PrEP (iPrEx, 2010) 44% (15, 63) 1% tenofovir gel (CAPRISA 004, 2010) 39% (6, 60) Immediate ART for HIV+ partner (HPTN 052, 2011) 96% (82, 99) TDF/FTC oral PrEP (TDF2, CDC, 2011) TDF oral PrEP (Partners PrEP, 2011) 63% (22, 83 ) TDF/FTC oral PrEP (Partners PrEP, 2011) 62% (34, 78) 73% (49, 85) What Works in HIV prevention, 7/12 Note: Does not include flat results from FEM-PrEP and VOICE arms

TDF/FTC : Gilead approves oral PrEP with TDF/FTC July 2012

Three-Part Agenda for Ending AIDS COMBINE Deliver proven tools for immediate impact Model successful programs Mobilize demand for new tools Reprogram resources for impact Fund evidence-based scale-up Testing Treatment Male Circumcision Demonstrate proven tools for immediate impact Plan for rollout in different settings Prioritize use of tools for greatest impact Pilot to guide real-world implementation PrEP Microbicides Develop long-term solutions to end the epidemic Sustain research funding to capitalize on new scientific insights Other ARV-based px Vaccines Functional Cure Years to ImpactZero to 55 to 1010 to End GOAL: A sustained decline in HIV infections (now at 2.7 million/year)

Combining effective prevention Hallett, T., et al., Imperial College London (2011)

ART ARV Long-acting methods Microbicides Multi-purpose technologies PrEP Treatment as prevention Topical PrEP Substances that can block HIV in the vagina or rectum—refers to a range of products including topical PrEP, non-ARV-based compounds and/or “multi-purpose” technologies. Antiretroviral therapy—the combination of medications leading to viral suppression in people living with HIV. Antiretrovirals—treaments drugs individually or co-formulated. Potentially strategies, such as a periodic shot of ARVs or a viginal ring (inserted monthly), which could potentially provide continuous protection against HIV. The emerging term for combination HIV prevention, STI prevention and/or contraceptive products. Pre-exposure prophylaxis using ARVs. ARV-based microbicides. Systemtic use of ART to reduce sexual transmission risk in HIV- positive people. Also known as TasP, T4P, TisP and TLC+ (testing, linkage to care plus treatment). Source: AVAC Report 2011: The End? Mind the Language

Real-world challenges: treatment cascade

Invest Now to Save Lives and Funds AIDS Deaths Baseline Investment Framework AIDS deaths averted between 2011 and million Baseline Investment Framework New infections averted between 2011 and million New HIV infections Cost (billions US$)

1.No magic bullet; need smart combinations 2.It’s behavior, stupid! 3.Adherence, adherence, adherence 4.Embrace the niche 5.Strategize the sequence 6.Testing, testing, testing 7.Watch our language 8.Money, money, money 9.Scientific data do not change the world—programs and policies backed by civil society, donors, implementers and governments do 10.Five questions Top 10 for 2012 and beyond

Five Questions  Who needs what?  Who wants what?  Who gets what?  Who pays?  Who decides?