UNAIDS Programs for young women and adolescent girls

UNAIDS防治五大支柱 • Programs for young women and adolescent girls and their male partners • Key population services • National condom programs • Voluntary medical male circumcision in priority countries • Pr. EP for population groups at higher risk

Number of people newly infected with HIV Source: UNAIDS/WHO estimates. The red shading shows future targets.

From: Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIVPositive Partner Is Using Suppressive Antiretroviral Therapy JAMA. 2016; 316(2): 171 -181. doi: 10. 1001/jama. 2016. 5148 Figure Legend: Rate of HIV Transmission According to Sexual Behavior Reported by the HIV-Negative Partner. Denominators are the group-specific number of HIV-negative participants who contributed eligible couple-years of follow-up. The upper limit of the 95% confidence interval was estimated using the exact Poisson method. Date of download: 11/17/2016 Copyright © 2016 American Medical Association. All rights reserved.

WHO治療指引 • Efforts should be made to reduce the time between HIV diagnosis and ART initiation based on an assessment of a person’s readiness. • ART should be initiated in all adults living with HIV, regardless of clinical stage and at any CD 4 cell count • As a priority, ART should be initiated in all adults with severe or advanced HIV clinical disease and adults with CD 4 count ≤ 350 cells/mm 3 WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 9

57% reduction The INSIGHT START Study Group. N Engl J Med 2015; 373: 795 -807.

Kaplan–Meier Estimates for Partner-Linked and Any HIV-1 Transmission and for Clinical and Composite Monitoring Events. 93% risk reduction Cohen MS et al. N Engl J Med 2011; 365: 493 -505.

自我篩檢 WHO. Landscape for HIV rapid diagnostic tests for HIV self-testing Semi-annual update - December 2016

台灣面臨的挑戰 • The numbers of HIV-infected people in Taiwan reached 30, 000 in July, 2015 • HIV prevalence is more than 1‰ • Despite the long-term health education related to safer sex, the annual new infections still account around 2, 200 persons in recent years 16

暴露前預防性投藥 • HIV Pre-exposure prophylaxis (Pr. EP) is a new prevention strategy • The fixed-dose drug, called Truvada, is taken once daily by HIV uninfected persons • Detectable serum drug inhibits HIV replication • Reduce the probability of getting infection when people expose to HIV virus during sex Plosker, G. L. (2013). Emtricitabine/tenofovir disoproxil fumarate: a review of its use in HIV-1 pre-exposure prophylaxis. Drugs, 73(3), 279 -291. 17

臨床試驗 • Among MSM – 44% reduction in the incidence of HIV among MSM who took Pr. EP daily • Heterosexual and Intravenous drug users – Risk reduction has been also observed during vaginal intercourse – Significant risk reduction of 49% among Intravenous drug users Grant. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med, 363(27), 2587 -2599. Spinner. (2015). HIV pre-exposure prophylaxis (Pr. EP): a review of current knowledge of oral systemic HIV Pr. EP in humans. Infection. 18

Spinner. (2015). HIV pre-exposure prophylaxis (Pr. EP): a review of current knowledge of oral systemic HIV Pr. EP in humans. Infection. 19

預防效果的差異性 • Risk reduction increased to 86%– 92% among those with detectable drug serum level compared with those without detectable drug • MSM taking Pr. EP less than 2 days per week, the risk reduction was only 44% without significant – 2 to 3 days per week, the risk reduction raises to 84% – More than 4 days per week, the efficacy is up to 95% Wilton. (2015). Pre-exposure prophylaxis for sexually-acquired HIV risk management: a review. HIV AIDS (Auckl), 7, 125 -136. Grant. (2014). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis, 14(9), 820 -829. 20

Pre-exposure prophylaxis and HIV incidence Grant. (2014). Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis, 14(9), 820 -829. 21

藥物動力學的優勢 • Drug concentration in genital secretions were 2. 5 -fold greater than in blood plasma • In rectal tissue, the concentrations were 100 times higher than in vaginal and cervical tissues • Anal sex is the major sex behavior among MSM, Pr. EP could become the important HIV prevention methods Patterson. (2011). Penetration of tenofovir and emtricitabine in mucosal tissues: implications for prevention of HIV-1 transmission. Sci Transl Med, 3(112), 112 re 114. 22

On- demand Pr. EP Spinner. (2015). HIV pre-exposure prophylaxis (Pr. EP): a review of current knowledge of oral systemic HIV Pr. EP in humans. Infection. 23

US prevention cascadee Kelley. Applying a Pr. EP Continuum of Care for Men Who Have Sex With Men in Atlanta, Georgia. Clin Infect Dis. 2015 Nov 15; 61(10): 15907. doi: 10. 1093/cid/civ 664. Epub 2015 Aug 13. 26

Toxicity • The toxicities have been mostly short-term side-effects such as nausea, headaches, and weight loss • Longer-term effects such as decline in renal function and loss of bone density have been seen in longer term use in HIV positive patients – Cabotegravir (an injectable medicine) – Tenofovir alafenamide (precursor to tenofovir)

Risk compensation • Providers have expressed reservations about offering Pr. EP • No increase in rate of sexually transmitted infections and the use of condoms has been fairly constant during the study period • An association of greater adherence in men who have higher risk sexual contact, rather than an increase in risky behaviors

Marcus. No evidence of sexual risk compensation in the i. Pr. Ex trial of daily oral HIV preexposure prophylaxis. PLo. S One. 2013 Dec 18; 8(12): e 81997. 30

MSM使用意圖相關因子 • Higher perceived susceptibility, higher perceived benefits and higher self-efficacy were associated with high Pr. EP intention • Higher perceived severity was not associated – The ceiling effect may explain it – More emphasis on disease severity could not be a proper strategy in increasing Pr. EP uptake Huang ST. HIV Pr. EP Use Intention and Associated Health Beliefs among Young Men Who Have Sex with Men 32

MSM使用意圖相關因子 • We can well explain the risk of HIV infection to MSM during health communication • The benefits about Pr. EP should be well informed to MSM • Pr. EP can be recommended to MSM who express high confidence in clinical visits • The limited resource could be give directly to the target populations Huang ST. HIV Pr. EP Use Intention and Associated Health Beliefs among Young Men Who Have Sex with Men 33

MSM使用意圖相關因子 • High perceived barriers is associated with lower Pr. EP intention compared with low perceived barriers • The barriers should reach the threshold to hinder MSM from taking Pr. EP • To promote Pr. EP, the plan should remove the barriers as much as possible Huang ST. HIV Pr. EP Use Intention and Associated Health Beliefs among Young Men Who Have Sex with Men 35

Rallying the troops • AIDS workers face setbacks, both epidemiological and financial – Oral Pr. EP – Vagina ring – Vaccine • Don’t mention the “C” word • With the new tools now available, and with but a little more willpower, AIDS can surely be beaten