The case for HIV treatment as prevention

HIV treatment continues to be a lifeline for people living with the condition and it is a subject that continues to interest anyone remotely interested in the issue. It is difficult to comprehensively write on this subject and that is why I keep coming back to it. As many of you are already aware, the initial purpose of HIV treatment (also referred to as antiretroviral therapy, combination therapy or Highly Active antiretroviral therapy) was to prolong the lives of those already living with HIV. The challenges of course have always been accessibility and affordability, particularly for those in the developing world. But a new phenomenon has been emerging for some time now, showing that the very same HIV drugs can be used just as effectively as preventative interventions.

HIV treatment as prevention is an intervention that applies antiretroviral treatment to reduce the chance of transmission. For example, antiretroviral treatments are provided to HIV positive mothers during pregnancy, labour and breastfeeding to stop them transmitting HIV to their babies – a method referred to as the prevention of mother to child transmission. In my previous blogs, I have also touched on post-exposure prophylaxis (PEP) for rape victims, microbicide trials, and most significantly the CAPRISA trial which used the antiretroviral drug Tenofovir.

Interestingly, one of the most controversial areas of HIV treatment as prevention was outlined in the Swiss Statement about three years ago, which basically stated that if a HIV positive person is on consistent HIV treatment with an undetectable viral load for six months coupled with no other sexually transmitted infections, the risk of actually transmitting HIV through sexual intercourse is small. When a person is on antiretroviral therapy, the amount of virus circulating in their blood and or bodily fluids is significantly diminished and that in turn lowers the possibility of passing the virus on. Before the Swiss Statement was published, some HIV doctors and patients were already aware of this, but the statement worried many HIV prevention enthusiasts in terms of how it might be interpreted and the lack of clarity on whether this applied to both heterosexual and same sex couples. Since then, further studies have proved that HIV positive people on antiretrovirals are far less likely to transmit HIV to negative partners, than those not taking the drugs.

So what does all of this evidence mean for HIV prevention, and how can we transfer research to policy and finally into practice? These are questions that health experts are wrestling with during discussions with a whole range of stakeholders, including activists. At the last International AIDS Society conference in Rome in July 2011, the chair of the conference, Dr. Elly Katabira, urged participants to optimise the impact of the medical evidence available and seize the opportunity because failure to act was not an option. As honourable as these words may be, I fear that there are some major obstacles that may delay the progress in this area.

In June 2011, at the high level meeting on HIV at the UN in New York, many countries pledged to deliver HIV treatment to 15 million people living with the virus by 2015. Many of the HIV commitments previously made globally have either been delayed or not kept due to lack of political will and a genuine lack of funding, amongst other things. In the current economic climate with many donor countries having to focus on their own financial woes, I am sceptical that HIV treatment is going to be on top of any government’s agenda, let alone HIV treatment as prevention.

Presently, we are still only reaching less than 40% (six million out of 15 million) of people who desperately need HIV treatment. The priority should be making sure that the remaining nine million who need treatment finally get it. Of course, putting people on treatment to prevent new infections is a cost-effective approach in the long run we have to consider the long-term impacts which we still do not know enough about?

The choices we are faced with are difficult ones. There are definitely good arguments to build on the progress made on the HIV treatment as prevention interventions, but unless the economic environment improves and other opportunities for funding are identified, getting those nine million people on treatment because they need it right now to live should be our priority!

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