British Columbia
Centre for Excellence
in HIV/AIDS
Treatment as Prevention:
HAART Expansion - A Powerful Strategy to
Reduce AIDS Morbidity and Mortality and HIV
Incidence
Julio Montaner MD, FRCPC, FCCP, FRSC
Director, BC-Centre for Excellence on HIV/AIDS, Providence Health Care
Professor of Medicine and Head, Division of AIDS, University of British Columbia
President, International AIDS Society
IAC, 2010, Vienna
HAART Can Reduce HIV Transmission
HAART stops HIV replication

HIV levels fall to undetectable in blood
as well as in sexual fluids

Sharp reduction in HIV transmission
Prevention Strategies
- Education
- Change in behavoir
- Harm reduction
- New strategies/technology
- Vaccines
Existing strategies have failed
to contain the global HIV pandemic
Impact of HAART on IDUs
 Morbidity and Mortality
 Incidence
Wood et al, BMJ, 2009
Wood et al, BMJ, 2009
Whiskers represent 95% confidence
intervals.
Wood et al, BMJ, 2009
Whiskers represent 95% confidence
intervals.
Wood et al, BMJ,
May 16, 2009
Cost Effectiveness of HAART
Revisited
Unique Study Features:
• Population Based
• Free Access to HAART and Medical Monitoring
• Centralized Data Capture / Single Source
• Access to Blood Borne Dxs – BCCDC
• Retrospective & Prospective Phases
January 2004
Summer of 1996
Summer of 1996
Phase I
Phase II
Year
Phase III
Montaner et al, Lancet, June 18th 2010
Incidence/yr
Viral load
< 50/mL (%)
Acquired resistance
falling
90
80
70
60
Plasma viral load
suppression rising
Highest
HIV-1- Plasma
Viral load per
Year
Number of patients
4,000
Non IDU
3,000
2,000
1,000
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
y ear
500 - 3499
< 500
IDU
1,000
y ear
³ 5 0,00 0
10 ,000 - 4 9,99 9
35 00 - 999 9
50 0 - 3 499
The proportion of HIV infected IDUs engaged in care in BC with plasma
viral load >1500 c/mL, as a surrogate for “high” community HIV-1-viral
load, decreased from ~50% in 2000-04 to ~20% in 2009 (p<0.001)
Montaner et al, Lancet 2010
< 5 00
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
0
1997
Ever on Treatment
&
Censoring at the time
of Death or Move
2,000
3500 - 9999
1996
10,000 - 49,999
Number of patients
³ 50,000
“Provincial Viral Load”
All Patients Ever Tested for Plasma HIV-1-Viral Load in BC
11,000
10,000
Censoring at the time of Death or Move
9,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
year
³ 50,000
10,000 - 49,999
3500 - 9999
500 - 3499
< 500
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
0
1996
Number of patients
8,000
Number of HIV tests per Year in BC
1994
BC-CDC Report, 2009
2000
2008
Hepatitis C, 1999-2008
• BC
Infectious Syphilis, 1999-2008
2004
• BC
2004
x Canada
x Canada
Genital Chlamydia, 1999-2008
Gonorrhea, 1999-2008
x Canada
• BC
x Canada
2004
• BC
2004
Key Findings:
Overall correlation between the number of pts on HAART and
the number of new HIV cases diagnosed per year was -0.89
(p<0.0001)
For every 100 additional patients on HAART, the number of new
HIV cases decreased by a factor of 0.97 (95% CI 0.96-0.98)
• ie: new HIV diagnoses fell by 3%.
For every 1 log10 decrease in viral load, the number of new HIV
cases decrease by a factor of 0.86 (95% CI 0.75-0.98)
Incremental
net benefit
(Millions of
CDN $) over 30
years
K Johnston et al,
AIDS, 2010
Combination prevention
Biomedical
Interventions
Structural
Interventions
HIV
Prevention
Community
Interventions
Modified from T. Coates
HIV testing,
linkage to care
and expanded
HAART
coverage
Individual
and small
group
behavioral
interventions
British Columbia
Centre for Excellence
in HIV/AIDS
Thank You
Supported by the Province of British Columbia; the Canadian Institutes of Health Research
(CIHR); and the National Institute on Drug Abuse, US-NIH.
Additional support has been provided by Merck, Gilead and ViiV Healthcare