1. British Columbia
Centre for Excellence
in HIV/AIDS
NIDA Satellite
at the 2008 International AIDS Conference
Julio Montaner MD, FRCPC, FCCP
Director, BC-Centre for Excellence on HIV/AIDS
Professor of Medicine and Chair, AIDS Research
Providence Health Care - University of British Columbia
President-Elect, International AIDS Society
Expanding HAART to Curb the
Spread of HIV/AIDS
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2. Prevention Strategies
- Education
- Change in behavior
- Harm reduction
- New strategies/technology
- Vaccines

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5. Effect of HAART on HIV
Transmission
• MTCT
• Discordant Couples
• Ecological Evidence

6. The Impact of HAART on MTCT
USA, 1985 - 2000
Canada, 1990 - 2004

7. Castilla, et al. JAIDS 2005; 40:96-101
Effect of HAART on Heterosexual
Transmission of HIV - Spain
8.6%
10%
0%
0
1
2
3
4
5
6
7
8
9
10
No Therapy Mono or BI
Therapy
HAART
P = 0.0129 HAART
vs other options

8. Decreased HIV Transmission after a Policy of
Providing Free Access to Highly Active
Antiretroviral Therapy in Taiwan
JID 2004:190 (1 September), 879.
Chi-Tai Fang,1
Hsu-Mei Hsu,2
Shiing-Jer Twu,2
Mao-Yen Chen,1
Yu-Yin Chang,3
Jing-Shiang Hwang,4
Jung-Der Wang,1,3
Che-Yen Chuang,1
and
the Division of AIDS and STD, Center for Disease Control, Department of Health, Executive Yuan.

9. New HIV and Syphilis in BC
0
5
10
15
20
25
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
HIV
Syphillis
Rateper100,000population
M REKART, BC-CDC, 2006

10. 0
100
200
300
400
500
600
700
0 1 2 3 4 5 6 7 8
24 months
Baseline
Plasma Viral Load (log10 copies/mL) Distribution
V Dias Lima et al. Unpublished; 2006.
Impact of HAART in BC-CfE
Frequencyofpeople

11. V D Lima et al
JID July 1st 2008

12. R2
= 0.90 R2
= 0.97
0
500
1000
1500
2000
2500
3000
3500
4000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Date
NumberofParticipants
Model DTP
Poly. (Model) Poly. (DTP)
p-value = 0.6423
R2
= 0.85 R2
= 0.73
0
100
200
300
400
500
600
700
800
900
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Date
HIVIncidence(N)
BC-CDC Model
Poly. (BC-CDC) Poly. (Model )
p-value = 0.5579
V D Lima et al
JID July 1st 2008

13. Adherence: 0% - <40%
Guideline: ≤200 cells/mm3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%
Coverage:
Current Adherence: 78.5%
Guideline: ≤200 cells/mm3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
Adherence: 80% - <95%
Guideline: ≤200 cells/mm3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
Adherence: 95% - 100%
Guideline: ≤200 cells/mm3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
Adherence: 0% - <40%
Guideline: ≤350 cells/m m3
100
150
200
250
300
350
400
450
500
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%
Coverage:
Current Adherence: 78.5%
Guideline: ≤350 cells/mm 3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
Adherence: 80% - <95%
Guideline: ≤350 cells/m m3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
Adherence: 95% - 100%
Guideline: ≤350 cells/m m3
100
150
200
250
300
350
400
450
500
550
1995 2000 2005 2010 2015 2020 2025 2030 2035
Year
NumberofNewInfections
50% 75% 90% 100%Coverage:
CD4 200/mm3
Adh <40%
CD4 200/mm3
Adh 40 - 80%
CD4 200/mm3
Adh 80 - 95%
CD4 200/mm3
Adh 95 - 100%
CD4 350/mm3
Adh <40%
CD4 350/mm3
Adh 40 - 80%
CD4 350/mm3
Adh 80 - 95%
CD4 350/mm3
Adh 95 - 100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
50%
75%
90%
100%
V D Lima et al
JID July 1st 2008

14. Impact of HAART on Viral Load
at the Population Level in BC

15. Community plasma HIV RNA among a cohort of
injection drug users in Vancouver
Whiskers represent 95% confidence intervals.
Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008

16. Community plasma HIV RNA levels and HIV
incidence among two parallel cohorts of IDUs
HIV incidence is expressed as incidence density per 100 person years.
Whiskers represent 95% confidence intervals.
Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008

17. Cox proportional hazards regression of the time
to HIV infection among 1,048 HIV negative IDUs
followed between May 1, 1996 and Dec 31, 2004.
Characteristic
Relative
Hazard
95% Confidence
Interval
p-value
Community Viral Load
Per log10 increase 9.40 (4.28 Š 20.64) < 0.001
Unsafe sex
Yes vs No 0.82 (0.56 Š 1.21) 0.360
Used syringe borrowing
Yes vs No 1.70 (1.15 Š 2.51) 0.008
Ethnicity
White vs Other 0.55 (0.39 Š 0.78) < 0.001
Heroin injection
> Daily vs < daily 1.19 (0.83 Š 1.70) 0.349
Cocaine injection
> Daily vs < daily 2.88 (1.99 Š 4.17) < 0.001
Unstable housing*
Yes vs No 1.40 (0.98 Š 2.02) 0.067
Plasma HIV R NA was time updated based on median value in the BART cohort during the 6 month
period prior to each HIV-negative participantÕsfollow-up visits;
ą
Defined as insertive or receptive vaginal or
anal intercourse; *Defined as living in a single room occupancy hotel, shelter, recovery or transition house,
jail, on the street, or having no fixed address;
Montaner et al, Late breaker, IAS-IAC, Mexico, August 2008

18. Estimated HIV burden in B.C.

19. 0
1000
2000
3000
4000
5000
6000
7000
8000
HIV+ (Est) HIV+
Aware
HIV+
HAART
Eligible
HIV+ on
HAART
HIV+
Eligible not
on
HAART
Estimated HIV burden in B.C. (2006)
Non IDU IDU

20. HIV among Injection Drug Users
BC - 2006 - n=4770
0
1000
2000
3000
4000
5000
6000
HIV+ Total
(Est)
HIV+ Aware HIV+
HAART
Eligible*
HIV+ on
HAART
HIV+
Eligible*
not on
HAART
* Based on a CD4 Cell count ≤ 200/mm3

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22. Cumulative all-cause (A) and non-accidental (B) mortality
rate among 3116 antiretroviral-naïve patients initiating
HAART
Highly Active Antiretroviral Therapy and Survival in HIV-infected IDUs.
Wood E, Hogg R, Dias Lima V, Kerr T, Yip,B, Marshall B, and Montaner
J. JAMA, 2008, in press

23. A Proposal to Evaluate the Impact of
Expanding HAART on HIV Incidence among
Injection Drug Users in British Columbia
Intervention 3 years Primary Endpoint
HAART Expansion HIV Incidence*
within 2008 guidelines
Seconday Endpoints:
mortality and morbidity
HIV-1-RNA Levels
HIV resistance
CD4 cell counts
adverse events and safety labs
hospitalizations
resource utilization
adherence to HAART
* Primary analysis = HIV incidence pre-HAART expansion vs year 3

24. Expansion of HAART for HIV
Prevention: Challenges
 Untested hypothesis
 Safety/toxicity
 Individual rights
 Resistance
 Hidden epidemics
 Logistics
 Erosion of prevention effort
 Cost
This hypothesis needs to be urgently explored

25. Expansion of HAART for HIV
Prevention: Challenges
 Untested hypothesis
 Safety/toxicity
 Individual rights
 Resistance
 Hidden epidemics
 Logistics
 Erosion of prevention effort
 Cost
This hypothesis needs to be urgently explored
However, our goal is
to characterize
changes in HIV
incidence resulting
from expanding
HAART use within
those in medical need

26. Seek and Treat to Optimally Prevent
HIV & AIDS in Injection Drug Users
STOP HIV & AIDS in IDUSTOP HIV & AIDS in IDU
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