Slide 1 of 42
Treatment as Prevention:
The Key to an AIDS-Free Generation
Julio S. G. Montaner, MD
Professor of Medicine
University of British Columbia
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
IAS–USA
Slide 2 of 20
Impact of HAART in BC-CfE
140
Death Rate per 1000
120
30
100
25
80
20
60
15
40
10
20
5
0
0
1993-94 1995-96 1997-98 1999-00 2001-02 2003-04
Life Expectancy at age 20
35
1993-94
1995-96
1997-98
1999-00
2001-02
2003-04
Modified from Hogg et al, Lancet. 2009
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 3 of 20
New HIV and Syphilis in BC
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
BC-CDC, 2005
Slide 4 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 5 of 20
HAART stops HIV replication

HIV load falls to undetectable levels in plasma
as well as in sexual fluids

Sharp reduction in HIV transmission
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 6 of 20
Slide 6 of 20
Wood et al, BMJ, 2009
Whiskers represent 95% confidence intervals.
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 7 of 20
HAART Reduces HIV incidence in IDUs
• From 1997, HIV incidence decreased by 74%
for each log decline in community HIV viral load
• In a separate model, HIV incidence decreased
by 5% for each 1% increase in HAART coverage
Modified from G Kirk et al, for the Alive Cohort, CROI 2011
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 8 of 20
HPTN 052: Immediate vs Delayed ART
in Sero-discordant Couples
%
Deferred
HR = 96.3% reduction in
transmission
No difference whether index
pt was M or F
Immediate
Cohen MS, et al. IAS 2011. Abst MOAX0102
Cohen MS, et al. N Engl J Med. 2011
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 9 of 20
Increasing HAART Coverage within
Evolving Guidelines in BC
N = 7492 by the
end of 2011
January 2004
Summer of 2000
Summer of 1996
Phase I
Phase II
Phase III
Year
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Montaner et al, Lancet, 2010
Slide 10 of 20
BC: AIDS Cases Diagnosed
(Rate per 100K)
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 11 of 20
BC: All Cause
Mortality (#)
All Cause Mortality in BC
400
350
300
Frequency
250
200
150
100
50
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Years Montaner et al, TasP Workshop, April 2012
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 12 of 20
Increasing HAART Coverage within Evolving
Guidelines in BC - Impact on New Diagnoses
From JSUpdated
Montaner,from
MD, at
San Francisco,
March2010,
29, 2013,
IAS-USA.
Montaner
et al, CA:
Lancet,
presented
at
TasP-Workshop, Vancouver 2012
Hepatitis C, 1999-2008
• BC
Slide 13 of 20
Slide 13 of 20
Infectious Syphilis, 1999-2008
2004
• BC
2004
x Canada
x Canada
Genital Chlamydia, 1999-2008
Gonorrhea, 1999-2008
• BC
x Canada
x Canada
2004
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
• BC
2004
Slide 14 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 15 of 20
Routine HIV testing - Acute Care
Department of Medicine Chart Audit Data: October 2011 –December 2, 2012
Site1
Number
of
Admissi Number
ons
Offered
Number
Tested
Acceptance
Rate2
% Offered
% Tested
Number of Positivity Rate
Positives
per 1000
SPH 3610 1626 1370
97%
45%
38%
11
~ 8/1000
MSJ 1556 994
740
85%
64%
48%
3
~ 4/1000
VGH 2087 1512 1196
96%
34%
27%
4
~ 3/1000
Total 9653 4132 3306
94%
43%
34%
18
~ 5/1000
1 Departments of Medicine only at each hospital site
2 Acceptance rate excludes all “Not Accepted”
(i.e. recent test, known HIV positive) except Pt Refusal
Preliminary Results, Courtesy of Scott Harrison et al
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 16 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 17 of 20
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Slide 18 of 20
Spectrum of Engagement in Care - USA
19% are estimated to be
undetectable as a result of
HAART use*
* More recently CDC-USA revised the estimate to 28%
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
Gardner et al. CID, 2011
Slide 19 of 20
The Cascade of Care - 1996-2010
80%
70%
60%
50%
2010
2009
2008
2007
2006
2005
2004
40%
30%
2003
20%
2002
2001
10%
2000
1999
0%
1998
1997
1996
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.
*
Nosyk et al, CROI, 2013
Slide 20 of 20
Lives Saved (x 1,000)
U$A Billions
Granich et al
From JS Montaner, MD, at San Francisco, CA: March 29, 2013, IAS-USA.