Moving PrEP Forward Where We Are & Where We Need to Go - - PowerPoint PPT Presentation

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Moving PrEP Forward Where We Are & Where We Need to Go - - PowerPoint PPT Presentation

Oct 12, 2022 111 likes •402 views

Moving PrEP Forward Where We Are & Where We Need to Go Christopher Hurt, MD Assistant Professor of Medicine Division of Infectious Diseases Overview Recent study results & some context Epidemiology o Modeling the impact of PrEP

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Moving PrEP Forward

Where We Are & Where We Need to Go

Christopher Hurt, MD

Assistant Professor of Medicine Division of Infectious Diseases

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SLIDE 2

Overview

  • Recent study results & some context
  • Epidemiology
  • Modeling the impact of PrEP
  • PrEP in the real world
  • Uptake and utilization in US
  • Is PrEP reaching those at risk?
  • Advancing a PrEP agenda for NC
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What is pre-exposure prophylaxis?

Use of antiretroviral medications before an exposure, to reduce the risk of becoming infected Tenofovir (TDF) is the most studied agent for PrEP

  • Properties of drug allow infrequent dosing
  • Few drug-drug interactions
  • Safe and well tolerated

FDA approved in 2012

(emtricitabine / tenofovir DF = Truvada)

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When taken consistently,

  • ral PrEP reduces risk of

HIV infection by

Grant RM, et al. NEJM. Dec 2010;363(27):2587-99 Baeten JM, et al. NEJM. Aug 2012;367(5):399-410 Grant RM, et al. Lancet Inf Dis. Sep 2014;14(9):820-9 Martin M, et al. AIDS. Apr 2015;29(7):819-24

90-100%

among cisgender MSM, heterosexual men & women, and transgender women. (84% among PWID)

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PrEP 2.0 is coming…

cabotegravir-LA INI broadly neutralizing monoclonal antibodies (bnAbs) dapivirine NNRTI FTC / TAF

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SLIDE 6

Hess K et al. CROI 2016, abstract #52 Map from CDC website: http://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html Highest – Lowest

Lifetime risk of acquiring HIV

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SLIDE 7

Hess K et al. CROI 2016, abstract #52 Map from CDC website: http://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html Highest – Lowest

1 in 93

North Carolinians

Lifetime risk of acquiring HIV

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Lifetime risk of acquiring HIV

Hess K et al. CROI 2016, abstract #52

2

  • ut of 100

Black women will become HIV+ If current diagnosis rates persist...

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Lifetime risk of acquiring HIV

Hess K et al. CROI 2016, abstract #52

9

  • ut of 100

White MSM will become HIV+ If current diagnosis rates persist...

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Lifetime risk of acquiring HIV

Hess K et al. CROI 2016, abstract #52

25

  • ut of 100

Hispanic MSM will become HIV+ If current diagnosis rates persist...

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Lifetime risk of acquiring HIV

Hess K et al. CROI 2016, abstract #52

50

  • ut of 100

Black MSM will become HIV+ If current diagnosis rates persist...

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Potential impact of interventions, 2015-2020

Yaylali E et al. CROI 2016, abstract #1051 Graphic from CDC

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Modeling the 10-year impact for MSM

Jenness S et al. J Infect Dis. 2016 [ePub ahead of print]

Proportion highly adherent 80% 60% 40% 20% 20% 40% 60% 80% Coverage

(Percent of at-risk MSM on PrEP)

Percentage of Infections Averted

33%

  • f expected

infections in next 10 years will be averted If 40% are covered and 62% take PrEP consistently...

Increasing coverage has a greater impact

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SLIDE 14

McCormack S, et al. Lancet. 2015;387(10013):53-60. http://www.thennt.com

544

MSM & trans women

½

started immediately

86%

protective effectiveness

(95%CI: 58, 96)

13

at-risk MSM need to be treated for 1 year to prevent 1 infection

(95% CI: 9, 23) For primary prevention: aspirin 1667 x 1Y statin 104 x 5Y

½

delayed initiation

PROUD – Nov 2012 - Apr 2014 PrEP really does work in the real world

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Kaiser SF, July 2012 - Feb 2015

Volk JE, et al. Clin Inf Dis. 2015 Nov 15.61(10):1601-3

1045

referrals for PrEP new HIV infections among PrEP users

80%

evaluated in person

388

person-years

  • f follow-up

82%

started PrEP

(62% of those referred)

187

new STIs among PrEP users

PrEP really does work in the real world

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PrEP really does work in the real world

McAllister S et al. ASM Microbe 2016, Abstract #371LB http://natap.org/2016/HIV/062216_01.htm

Men

n=7002

Women

n=1388

Transgender Women

n=76

Overall Total exposure, P-Y

6214 788 48 7061

Number of infections

64 2 1 67

Rate per 100 P-Y

(95%CI)

1.03

(0.80, 1.32)

0.25

(0.03, 0.92)

2.07

(0.05, 11.5)

0.95

(0.74, 1.2)

Review of 32 PrEP demonstration projects

  • 17 projects had no new infections
  • 2,467 participants à 1,315 P-Y of PrEP exposure
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PrEP is taking off in the US…

Rawlings K et al (McAllister presenting). IAC Durban 2016, abstract #TUAX0105LB http://www.natap.org/2016/IAC/IAC_17.htm

2500 5000 7500 10000 12500 15000

2012 2013 2014 2015

Individuals starting FTC/TDF for PrEP

USPHS / CDC guidelines issued

738%

increase

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PrEP is taking off in the US…

Rawlings K et al (McAllister presenting). IAC Durban 2016, abstract #TUAX0105LB http://www.natap.org/2016/IAC/IAC_17.htm

2500 5000 7500 10000 12500 15000

2012 2013 2014 2015

Individuals starting FTC/TDF for PrEP

79,684

individuals

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…but its distribution is uneven…

Rawlings K et al (McAllister presenting). IAC Durban 2016, abstract #TUAX0105LB http://www.natap.org/2016/IAC/IAC_17.htm

5000 10000 15000 20000 25000 30000 35000 40000

2012 2013 2014 2015

Individuals starting FTC/TDF for PrEP Women Men

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…but its distribution is uneven…

1000 2000 3000 4000 5000 6000 7000 8000

12 13 14 15 12 13 14 15 12 13 14 15 12 13 14 15

Individuals starting FTC/TDF for PrEP White Hispanic Black Asian Women Men

n=21,463

(44% of all started) Bush S et al. ASM / ICAAC 2016, abstract #2651

http://www.aidshealth.org/wp-content/uploads/2016/07/GILD_Bush-PrEP-Race-Utilization.ext-June-2016.pdf

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60,872

men

…and it’s not reaching those most at-risk

Rawlings K et al (McAllister presenting). IAC Durban 2016, abstract #TUAX0105LB http://www.natap.org/2016/IAC/IAC_17.htm

18,812

women

28%

< 25 yo

11%

< 25 yo

22%

  • f all new infections in

2014 among 13-24 yo

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…and it’s not reaching those most at-risk

Bush S et al. ASM / ICAAC 2016, abstract #2651

http://www.aidshealth.org/wp-content/uploads/2016/07/GILD_Bush-PrEP-Race-Utilization.ext-June-2016.pdf

Black Hispanic Asian Multi/Other White

US Population 2014 PrEP Utilization Sept 2015 New Infections 2014 (estimated)

62% 12% 18% 74% 27% 10% 12% 44% 23%

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Addressing barriers head-on

Hoots B et al. Clin Infect Dis. 2016:63(5):672-7. Hurt CB, Dennis AM. Sex Transm Dis. 2013;40(3):213-5. Hurt CB et al. JAIDS. 2012;61(4):515-21.

Nat’l HIV Behavioral Surveillance System (CDC)

  • Blacks & Whites equally willing to take PrEP
  • Educated & high income: more White users
  • YBMSM less likely to have an indication
  • ≥ 2 sex partners + (bacterial STI or UAI) in past 12m
  • 1 main HIV+ partner in past 12m
  • Behavior alone doesn’t explain differential risk…
  • Fewer missteps needed for YBMSM to acquire HIV
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Rural counties designated Health Professional Shortage Areas (specifically in need of primary care services)

Service gaps reflect structural barriers

Data from NC-DHHS Office of Rural Health

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Adherence Communities

  • f color

Structural barriers

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PrEP is now a matter of social justice

We need statewide partnerships to:

  • get the word out in innovative ways
  • ensure access in people’s own communities
  • help cis- and trans men and women enter care
  • alleviate barriers to retention and adherence
  • identify best practices in delivering PrEP
  • collect the data we need to demonstrate impact

We need the voices of advocates…

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PrEP is now a matter of social justice

We need statewide partnerships to:

  • get the word out in innovative ways
  • ensure access in people’s own communities
  • help cis- and trans men and women enter care
  • alleviate barriers to retention and adherence
  • identify best practices in delivering PrEP
  • collect the data we need to demonstrate impact

We need the voices of advocates…

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SLIDE 28

Questions?

Feel free to email me churt@med.unc.edu