HIV TODAY
Waiting for the next big
breakthrough?
Stevie Clayton
ACON CEO
NSW HIV Rural Forum 2007
HIV today
Globally:
• 40 million living with HIV
• 30 million have died
• Another infection every 7 seconds
• Another death every 11 seconds
Nationally:
• 17,000 living with HIV
• 7,000 have died
• Another 1,000 infections a year
• Increasing rate of infection
NSW:
• 10,500 living with HIV
• 4,000 have died
• 350-400 infections per year
• Stable rate of infection
Big Issues in HIV
Globally:
• Access to treatment
• Access to the means of protection
• Stigma & discrimination
Nationally:
• Increasing rates of HIV & STI
• Decreasing engagement with HIV
• Long term effects of treatment
NSW:
• Maintaining the plateau in rates of HIV
• Increasing STI
• Changing concepts of risk
• Long term effects of treatment
Diagnoses of HIV infection in
2000 Australia
1500
Number
1000
500
0
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Year
HIV diagnoses Newly acquired HIV
Source: State and Territory health authorities
Newly diagnosed HIV in Australia, 1996 –
8
2006, by year and State/Territory
7
Diagnosis rate per 100 000
6
5
4
3
2
1
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Newly acquired HIV infection, 1996 –
Diagnosis rate per 100 000 2.5
2006, by year and State/Territory
2
1.5
1
0.5
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Proportion of new HIV diagnoses that were newly
acquired, 1996 – 2006, by year and State/Territory
Proportion newly acquired 40
30
20
10
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Median age at HIV diagnosis among males,
40
1996 – 2006, by year and State/Territory
38
Median age (years)
36
34
32
30
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Median age at diagnosis of newly acquired HIV
infection among males, 1996 – 2006, by year and
40 State/Territory
Median age (years)
36
32
28
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Median CD4+ cell count at HIV diagnosis 1996 –
Median CD4 cell count
550
2006, by year and State/Territory
500
450
400
350
300
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Median CD4+ cell count at diagnosis of newly
850
acquired HIV infection, 1996 – 2006, by year and
State/Territory
800
750
Median CD4 count
700
650
600
550
500
450
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
Notifications of HIV in NSW residents, by year of diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas)
500
450
400
350
300
Notifications
HIV notifications
250
Newly acquired infections
200
150
100
50
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
HIV notifications in NSW residents, by sex and year of first diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas)
450
400
350
300
Notifications
250 Males
Females
200 Other
150
100
50
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
HIV notifications in NSW residents, by exposure and year of first diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas)
350
Homo/bisexual
Homo/bisexual & IDU
300 IDU
Heterosexual
Other
Not stated
250
Notifications
200
150
100
50
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
Newly diagnosed HIV infection, 1996 – 2006, with an
undetermined source of exposure to HIV, by year and
12 State/Territory
Percentage of diagnoses
8
4
0
1996 - 2000 2001 - 2005
Year
NSW QLD VIC Australia
Source: State and Territory health authorities
HIV notifications in NSW residents, by geographical area (inner Sydney) and year of
first diagnosis. 1996 to 2006.
(NB excludes cases previously notified in other states and overseas)
120
Male homo/bisexual
Male homo/bisexual & IDU
IDU
100 Heterosexual
Other
Not stated
80
Notifications
60
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
* Postcode of residence 2010, 2011, 2042, 2050
HIV notifications in NSW residents, by geographical area (other Sydney) and year of
first diagnosis. 1996 to 2006.
(NB excludes cases previously notified in other states and overseas)
160
Homo/bisexual
Homo/bisexual & IDU
140
IDU
Heterosexual
120 Other
Not stated
100
Notifications
80
60
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
* WS, SWS, NS, CS (excluding 2042, 2050), SES, (excluding 2010, 2011)
HIV notifications in males resident in NSW, by age group and year of first diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas
180
160
140
120
Notifications
0<15 yrs
100 15-19 yrs
20-24 yrs
25-34 yrs
80 35-44 yrs
45+ yrs
60
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis year
Rate of HIV notifications in males resident in NSW, by age group and year of first
diagnosis. 1996 to 2006. (NB excludes cases previously notified in other states and overseas
40
35
30
25
Rate per 100000
0<15 yrs
15-19 yrs
20-24 yrs
20
25-34 yrs
35-44 yrs
45+ yrs
15
10
5
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
HIV notifications in females resident in NSW, by age group and year of first diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas
30
25
20
0<15 yrs
Notifications
15-19 yrs
20-24 yrs
15 25-34 yrs
35-44 yrs
45+ yrs
10
5
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
HIV notifications in female residents of NSW, by exposure and year of first diagnosis.
1996 to 2006. (NB excludes cases previously notified in other states and overseas)
50
Heterosexual
45 IDU
Other
Vertical
40 Undertermined
35
30
Notifications
25
20
15
10
5
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Diagnosis Year
Key Issues for HIV Prevention
• Changing patterns of relationships
• Changing concepts of risk
• Sero-sorting
• Strategic positioning
• Withdrawal
• Viral-load monitoring
• Sexually transmitted infections
• Drug & alcohol use
Men who reported no current sex
partners
50
40
30
%
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Men in monogamous relationships
50
40
30
%
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Men who reported having casual
partners
80
70
%
60
50
40
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Proportion of men who
had 50+ partners in the past 6 months
HIV positive men HIV negative and unknown-serostatus men
30 30
20 20
%
%
10 10
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Unprotected anal intercourse with regular partners
(UAIR)
Note: the sample includes only men who had sex with regular partners
100
80
60
%
40
20
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Is there serosorting in HIV positive regular
relationships?
Caution: these proportions are based on small numbers of seroconcordant positive relationships
Proportion of relationships that UAIR in seroconcordant positive
were seroconcordant positive relationships
20 100
80
15
60
%
%
10
40
5
20
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Is there serosorting in HIV negative
regular relationships?
Proportion of relationships that UAIR in seroconcordant negative
were seroconcordant negative relationships
60
100
55
80
50
60
%
45
40
40
20
35
0
30 1998 1999 2000 2001 2002 2003 2004 2005 2006
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Proportion of relationships that are
serodiscordant or serononconcordant
Serodiscordant relationships Serononconcordant relationships
25
70
20
60
15
50
%
%
10
40
5
30
0 20
1998 1999 2000 2001 2002 2003 2004 2005 2006
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
UAIR in serodiscordant and nonconcordant
relationships
Note: the sample includes only men who had sex with regular partners
100
80
60
%
40
20
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Unprotected sex with casual partners
(UAIC)
Note: the sample includes only men who had sex with casual partners
50
40
30
%
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
UAIC, by HIV serostatus of respondents
HIV positive men HIV negative and unknown-serostatus men
80
80
60
60
%
%
40 40
20 20
0 0
1998 1999 2000 2001 2002 2003 2004 2005 2006 1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Men who reported UAIC and always disclosed serostatus
30
20
%
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Men who reported UAIC and never disclosed serostatus
100
80
60
%
40
20
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW
VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Men who never disclosed serostatus in the context of
UAIC,
HIV positive men by serostatus
HIV negative and unknown-serostatus men
100 100
80 80
60 60
40 40
20 20
0
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 1998 1999 2000 2001 2002 2003 2004 2005 2006
NSW VIC
QLD
Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49
Syphilis notifications (excluding congenital) in NSW residents, by year of disease
onset. 1996 to 2006
1200
1000
800
Notifications
Syphilis: infectious
600
Syphilis: All
400
200
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Infectious syphilis notifications in NSW residents, by sex and year of disease onset.
1996 to 2006
300
250
200
Notifications
Male
150 Female
Unknown
100
50
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of onset
Infectious syphilis notifications in male NSW residents, by age group and year of
disease onset. 1996 to 2006
120
100
80
0<15 yrs
Notifications
15-19 yrs
20-24 yrs
60
25-34 yrs
35-44 yrs
45+ yrs
40
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Gonorrhoea notifications in NSW residents, by year of disease onset. 1996 to 2006
1800
1600
1400
1200
Notifications
1000
Gonorrhoea
800
600
400
200
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Gonorrhoea notifications in NSW residents, by sex and year of diesase onset.
1996 to 2006
1600
1400
1200
1000
Notifications
Male
Female
800
Transgender
Unknown
600
400
200
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Gonorrhoea notifications in males resident in NSW, by age group and year of
disease onset. 1996 to 2006
600
500
400
0<15 yrs
Notifications
15-19 yrs
20-24 yrs
300
25-34 yrs
35-44 yrs
45+ yrs
200
100
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year of onset
Rates of gonorrhoea notifications in males resident in NSW, by age group and year of
disease onset. 1996 to 2006
140.0
120.0
100.0
Rate per 100000
0<15 yrs
80.0 15-19 yrs
20-24 yrs
25-34 yrs
60.0 35-44 yrs
45+ yrs
40.0
20.0
0.0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Onset Year
Chlamydia notifications (excluding congenital) in NSW residents, by year of disease
onset. 1999 to 2006
14000
12000
10000
Notifications
8000
Chlamydia: STI
6000
4000
2000
0
1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Chlamydia notifications in NSW residents, by sex and year of disease onset.
1999 to 2006
8000
7000
6000
5000
Notifications
Male
4000
Female
3000
2000
1000
0
1999 2000 2001 2002 2003 2004 2005 2006
Year of Onset
Chlamydia notifications in males resident in NSW, by age group and year of disease
onset
2000
1800
1600
1400
1200 0<15 yrs
Notifications
15-19 yrs
20-24 yrs
1000
25-34 yrs
35-44 yrs
800
45+ yrs
600
400
200
0
1999 2000 2001 2002 2003 2004 2005 2006
Year of onset
Rates of chlamydia notifications in males resident in NSW, by age group and year of
disease onset. 1998 to 2006
800
700
600
Rate per 100000
500 0<15 yrs
15-19 yrs
20-24 yrs
400
25-34 yrs
35-44 yrs
300 45+ yrs
200
100
0
1999 2000 2001 2002 2003 2004 2005 2006
Onset Year
Recent use of illicit drugs among gay men &
men in National Household Survey
100%
Any drug use Column 2 Ecstasy
Speed Amyl Marijuana
Column 10 Any injecting
80%
% 60%
40%
20%
0%
Sydney Melbourne Brisbane Household
Survey
National Survey = 12 months
Ecstasy – previous 6 months
60
50
40
%
Sydney
30 Melbourne
Brisbane
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Speed – previous 6 months
60
50
40
% Sydney
30 Melbourne
Brisbane
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Crystal – previous 6 months
60
50
40
%
Sydney
30 Melbourne
Brisbane
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Speed use among positive men – previous
6 months
60
50
40
%
Sydney
30 Melbourne
Brisbane
20
10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Crystal use among positive men –
previous 6 months
60
50
40
%
Sydney
30 Melbourne
Brisbane
20
10
0
2000 2001 2002 2003 2004 2005 2006
Injecting drug use in
previous 6 months
20
15 Sydney Melbourne Brisbane
%
10
5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Injecting drug use among positive men in
previous 6 months,1998-2006
25
20
Sydney Periodic
% 15
10 Melbourne Periodic
5
Brisbane Periodic
0
98
99
00
01
02
03
04
05
06
19
19
20
20
20
20
20
20
20
Drugs used in past 12 months -
Futures
100
NSW VIC QLD
80
60
40
20
0
l y l l
o ho tas my sta
alc ec
s a cry
Prevention in Rural Areas
• Use of the internet for sex & support
• Beats
• Perceptions of risk & mobility
• Sero-sorting may not work so well
• Isolation & peer support
• Young people
• Aboriginal people especially GLBT
Issues for plwha in 2007
• For majority – staying healthy
• Sex & disclosure
• Move from care & support to health
promotion
• 30% - complex needs
• Changing notions of identity
• More effective treatments
• Ageing
• Travel
• Stigma & discrimination
Plwha in rural areas
• Travel to access services
• Access to treatment
• Isolation – peer support
• Sometimes unreal expectations
• Differences in different areas
• Longer-term diagnosed
• More recently diagnosed
• Increased stigma & discrimination
‘New Kids on the Block’
• Extremely promising new antiretrovirals in the
‘pipeline’
• Three new classes of drugs:
– Integrase Inhibitors x 2
– CCR5 Inhibitors x 3
– Maturation Inhibitors x 1
• ‘New Generation’ of two existing classes:
– Protease inhibitors x 1
– Non-nuclear reverse transcriptor inhibitors x 2
• Currently most are in trial phases II and III of
development
New Classes of Drugs:
CCR5 Entry Inhibitors
Generic Pharma Phase Side Effect Comment
Maraviroc Pfizer US Colds and Better in
approved bronchitis early
infection
Vicriviroc Schering- Progressing Cancers in Better in
Plough to Phase III Ph II but early
linked ? infection
Pro-140 Progencis Phase II Injection Immediate
site drop in VL
reactions CD4 rise in
8 days
New Classes of Drugs:
Integrase Inhibitors
Generic Pharma Phase Side Effect Comment
Raltegravir Merck Phase III Nausea, Undetectable
Fast track headache at in 2 weeks
early 2009 induction
Elvitegravir Gilead Phase II Comparable Needs
to placebo Ritonavir
New Classes of Drugs:
Maturation Inhibitors
Generic Pharma Phase Side Effect Comment
Bevirimat Panacos Phase IIB Well Problems
tolerated with tablet;
trialling liquid
Existing Classes of Drugs:
‘New Generation’
Generic Pharma Phase Side Effect Comment
Etravine Tibotec Completing Mild rash Resistance in
(NNRTI) Phase III class OK
Rilpivirine Tibotec Phase III Mild rash; Resistance in
(NNRTI) lipid neutral class OK
Prezista Tibotec Released Well Resistance in
(PI) mid 07 tolerated class OK
Sydney: the ‘new Vancouver’
• Possibly the most exciting treatment news post-
Vancouver
• Early data:
– ‘Extremely potent’
– ‘Twice as effective’
– ‘Well tolerated’
– ‘Doubling of antiviral effect’
• High potency
• Low toxicity
• ‘New Generation’ of existing classes still provide
options to those with resistance patterns
Thanks to
• NCHECR
• Ann McDonald
• Garrett Prestage
• NCHSR
• Iryna Zablotska
• NSW Health
• Mark Bartlett
• ACON
• Russell Westacott
• Nick Corrigan
• Nic Parkhill