Introduction to HIV New
Prevention Technologies
(NPTs)
Core Competencies for Public Health
Public Health Sciences
Assessment and Analysis
Policy and Program Planning, Implementation and Evaluation
Partnerships, Collaboration and Advocacy
Diversity and Inclusiveness
Communication
Leadership
Learning Objectives
Introduction
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Describe the current state of HIV in Canada
Describe existing HIV prevention options
Describe emerging HIV prevention options and
how they work
Explain why there is a need for additional HIV
prevention options in Canada
Describe how NPTs fit into comprehensive
prevention and complement the existing
spectrum of HIV interventions
Identify means of staying informed and getting
involved in NPT-related work
Section 1: HIV in Canada
HIV in Canada
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Estimated number of people living with HIV
 57,000 in 2005
 65,000 in 2008
Estimated 2,200 – 4,200 new infections in 2005
Estimated 2,300 – 4,300 new infections in 2008
 44% gay, bisexual and men who have sex with men
 20% heterosexual/non-endemic
 16% heterosexual/endemic
 17% people who inject drugs
 3% gay, bisexual and men who have sex with men/people who
inject drugs
26% of HIV-positive Canadians (approx. 16,900) are unaware of
their status
PrEP
Treatment-as-Prevention
Male and female condoms
PEP
Vaccines
Microbicides
PMTCT
HIV
Prevention
Behaviour change
Male
circumcision
Clean injecting
equipment
Voluntary
counselling and
testing
Section 2: Why are new
HIV prevention options
needed?
Why are new HIV prevention
options needed?
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Many people want to be able to conceive—which is not possible
with male and female condoms.
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Receptive partners—whether male or female—are at highest risk
in sexual encounters, and often require prevention options that
they can better control.
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Many people are unable or unwilling to use condoms.
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We need HIV prevention tools that:
allow conception
are more within the control of receptive partners
enhance pleasure
do not form a physical barrier
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Experience of contraception:
More options = more protected sex acts
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Can’t we just promote condoms?
Can’t we just promote condoms?
Efficacy vs. effectiveness
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Efficacy = how well a product works under ideal
conditions
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Effectiveness = how well a product works in practice
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For example, condom efficacy is 80-95% when used
consistently and correctly. Their effectiveness is 69%
because some people don’t always use them correctly or
consistently.
Condoms and
NPTs
Condoms and
NPTs
Condoms and
NPTs
Section 3: NPTs as part of a
comprehensive approach
NPTs as part of comprehensive
approach to HIV Prevention
Imagine a full spectrum of
interventions
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Addressing social
determinants of health
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Male & female condoms
and lubricant
Rights-focused behaviour
change
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Treatment to prevent
vertical transmission
(PMTCT)
Voluntary counselling &
testing
Sexually transmitted
infection screening
and treatment
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Clean injecting
equipment
Antiretroviral treatment
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Treatment for
opportunistic infections
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Basic care/nutrition
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Prevention for positives
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Education and rightsfocused behaviour
change
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Therapeutic vaccines
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Functional cure
Post-exposure
prophylaxis (PEP)
Male medical circumcision Vaginal & rectal
microbicides
Pre-exposure prophylaxis
(PrEP)
Preventative vaccines
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Section 4: New HIV
Prevention Technologies
PrEP
Treatment-as-Prevention
Male and female condoms
PEP
Vaccines
PMTCT
HIV
Prevention
Male
circumcision
Clean injecting
equipment
Voluntary
counselling and
testing
What are “new” HIV prevention
technologies?
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Still in trials
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Preventive vaccines
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Proof-of-concept, but need
to confirm efficacy
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Vaginal and rectal
microbicides
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Recently proven effective
but not yet (widely)
available
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Pre-exposure prophylaxis
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Treatment-as-prevention
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Medical male circumcision
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Non-occupational PEP
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Female condoms
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Diaphragm/cervical barriers
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HSV-2 treatment
Antiretroviral (ARV)-based
Prevention Methods
Prior to exposure
Point of exposure
After exposure
Preventing vertical transmission (PMTCT)
PrEP
Vaginal and rectal microbicides
Treatment-asprevention
PEP
HIV prevention
Not ARV-based
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Male & female
condoms
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Circumcision
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Clean injecting
equipment
ARV-based
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Vaccines
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Voluntary
counselling and
testing
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Behaviour change
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Vaginal and
rectal
microbicides
Preventing
vertical
transmission
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PEP
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PrEP
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Treatment-asprevention
Treatment-as-prevention
The prevention benefits that come from HIV+
people using ARVs
 Treatment = less virus = less transmission
 Alternative names and concepts:
 Test and Treat (or TNT)
 Seek and Treat
 TLC+
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What we know about treatment-asprevention
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Works at the individual level
One trial among mostly heterosexual
serodiscordant couples showed a reduced risk of
transmission if HIV+ partner is on treatment.
Can it work at the population level?
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Increased testing = more knowledge of status =
less risk-taking
Increased testing = more HIV+ people on treatment
= less virus
Less risk-taking + less virus = less transmission?
Questions about “treatment-asprevention”
ARVs
for
prevention
Access to treatment
Knowledge of status
Pre-exposure prophylaxis (PrEP)
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The ongoing use of one or two antiretrovirals by HIVnegative individuals starting before an exposure and
continuing afterwards
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Infection does not occur instantly after an exposure to
HIV. The virus needs to spread throughout the body—
this may take up to 3 days after the exposure.
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The “window of opportunity” for PrEP: after an
exposure HIV has not yet spread throughout the body.
During this time, PrEP may be able to stop HIV from
causing an infection.
What we know about PrEP
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Using either the ARV tenofovir (Viread) or tenofovir+emthricitabine
(Truvada) in combination with a comprehensive package of
prevention services:
 One trial showed that PrEP (using Truvada) reduces the risk
of infection when used by gay men and other MSM, and
trans women.
 Two trials showed that PrEP (using either Viread or Truvada)
reduces the risk of infection when used by heterosexual men
and women.
 Two trials could NOT show that PrEP (using either Viread or
Truvada) reduces the risk of infection when used by
heterosexual women.
Effectiveness is linked to adherence.
The risk of side effects, toxicity, and drug resistance are low.
Questions about PrEP
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Safety/effectiveness of…
 a pill taken on a non-daily schedule
 other antiretrovirals
Safety/effectiveness of Viread and Truvada…
 among women
 in populations not included in trials
 over a longer period of time
 in the “real world”
PrEP has not yet been approved by Health Canada, but may
already be in use off-label.
Vaginal and rectal microbicides
A lube used before and during sex
A douche or enema used before and/or
after sex
A vaginal ring that stays in place for up to
a month
A suppository or a gel applied with an
applicator before sex
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What we know about vaginal
microbicides
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Using a gel with the ARV tenofovir, in combination with a
comprehensive package of prevention services:
 One trial showed that vaginal use of tenofovir gel before and
after sex reduced the risk of infection when used by
heterosexual women.
 One trial was unable to show that daily vaginal use of
tenofovir gel reduced the risk of infection when used by
heterosexual women.
Efficacy is linked to adherence.
The risk of side effects, toxicity, and drug resistance are low.
We need microbicides that:
 are both contraceptive and not contraceptive
 are inexpensive and easily available
 can be used without a partner’s active cooperation
Questions about vaginal and rectal
microbicides
Will we have microbicides that:
 help reduce the risk of getting other
sexually transmitted infections?
 can be used vaginally or rectally?
 can be used by HIV+ people (products not
based on ARVs)?
 Will we have rectal microbicides?
 Related question: Are currently available
(non-microbicide) lubricants safe?
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Vaccines
A substance (i.e. part of the virus) that
teaches the body to recognize and defend
itself against bacteria and viruses
 Causes a response from the immune
system—preparing it to fight if exposed to a
specific infection
 Not a cure
 Prevents infection or slows disease
progression
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What we know about vaccines
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Encouraging signs include:
 broadly neutralizing antibodies found.
 precedent for other diseases: success
against other viral infections.
 precedent from animal studies: long-term
control of infection in vaccinated monkeys.
 immune control of HIV-1: infected
individuals control infection.
Questions about vaccines
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Challenges remain
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Need a different approach for HIV vaccines.
Animal models: have not yet accurately predicted how
they will work in humans.
Correlates of protection: what immune responses will
protect an individual from infection is mostly unknown.
HIV mutations
HIV subtypes: there are many different subtypes of HIV
may require matching vaccines.
Section 5: NPT
Implementation Issues
NPT implementation issues
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Guidelines for front-line delivery should include
tools and protocols regarding:
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how to assess risk.
how to match NPTs with individuals and community needs.
how to support adherence and manage risk compensation.
how often to conduct HIV testing, STI screening and test
for drug resistance.
how to manage side effects for clinicians and consumers.
how to communicate about partial efficacy and
effectiveness.
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NPTs: Measuring impact
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Mechanisms required to measure:
 safety and toxicity
 adherence
 risk compensation
 impact on HIV incidence
Next Steps:
Actions that can be taken
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If you determine that your clients are at high risk of HIV…
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Urge them to get tested for HIV and STIs regularly.
Encourage risk reduction behaviours (safer sex, harm reduction).
Remind them to seek PEP as soon as possible after a potential HIV
exposure.
Suggest they talk to their doctor about HIV prevention options, including
PrEP.
If you want to engage actively in shaping the field…
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Urge public health officials to issue guidance on the use of NPTs.
Join a local committee or group addressing some of the social
determinants putting your clientele at risk of HIV.
Become involved in street outreach, support needle exchange and harm
reduction programs.
Join social justice groups fighting stigma and discrimination,
homophobia, racism, and gender violence.
Conclusion
Introduction
Additional Resources:
Fact Sheets, Resources & Reports:
 http://www.catie.ca/preventing-hiv/prevention-technologies
 http://www.avac.org/
Webinars & Courses:
 http://www.catie.ca/en/treating-hiv/new-hiv-prevention-technologiesand-their-implications-hiv-prevention-canada-webinar-se
 http://www.catie.ca/en/treating-hiv/topics-e-learning
 www.hivpreventionresearch.org
Listservs email:
 MAG-Net@cdnaids.ca
 rectalmicro@gmail.com