NAIROBI, 13 May 2011 (PlusNews) – A landmark study showing major reductions in HIV transmission among discordant couples due to early treatment may fail to have a significant impact on HIV prevention unless governments and donors are willing to turn the science into action, HIV advocates say.
“These are very exciting results that we hope will begin to change the debate and the discourse over the issues around HIV treatment and prevention,” Mitchell Warren, executive director of the AIDS Vaccine Advocacy Coalition (AVAC), told IRIN/PlusNews. “Coming right before the UN High Level Meeting on HIV in New York next month, we hope that the results will take the discussion from rhetoric to reality.”
While several observational studies have shown similar results, these are the first results from a major randomized clinical trial to indicate that treating an HIV-infected individual can reduce the risk of sexual transmission of HIV to an uninfected partner. Known as HPTN 052 and funded by the US National Institutes of Health, the trial was due to end in 2015 but an independent data and safety monitoring board recommended halting it early because of overwhelming evidence of benefits.
In 2010, UNAIDS launched a new HIV treatment and prevention approach, called Treatment 2.0, which aims to drastically scale up testing and treatment based on mounting evidence that people on ARVs are much less likely to transmit the virus. The organization estimates that successful implementation of Treatment 2.0 could avert 10 million deaths by 2025, and reduce new infections by one-third.
“Take the example of male circumcision as an HIV prevention tool – there were several observational studies that seemed to point to its effectiveness for HIV prevention, but it was not until the clinical trial results in Kenya, South Africa and Uganda that we saw guidelines, policies and programmes developed – and funding made available,” Warren said. “This is what we hope these results will achieve in terms of a targeted response to treatment and prevention within sero-discordant couples. We also hope to see more trials of other groups to strengthen the evidence further.”
HPTN 052 began in April 2005 and enrolled 1,763 couples in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the US and Zimbabwe. At enrolment, the HIV-positive partners had CD4 cell counts – a measure of immune strength – between 350 and 550 so were not eligible for ARVs based on most national guidelines. The UN World Health Organization recommends beginning ARVs at a CD4 cell count of 350 or below. The couples were randomly assigned to either a group where the HIV-positive partner received ARVs immediately, or to one where HIV-positive partners deferred initiation of ARV treatment until they were eligible under national guidelines.
Out of 28 HIV infections among study participants, 27 occurred among the 877 couples in which the HIV-infected partner did not begin antiretroviral therapy immediately. The study’s authors concluded that earlier initiation of HIV treatment led to a 96 percent reduction in HIV transmission to the HIV-uninfected partner.
“These results are the best evidence of the need for treatment, not just in cases of sickness, but also for prevention, especially in countries where new HIV infections are rising among couples,” Sharonann Lynch, HIV policy adviser for Médecins Sans Frontières (MSF). “It adds to the prevention toolbox we already have; we now have more tools than ever and we need to use all of them.”
“HIV-positive people are the happiest – they now know if they start treatment early they are unlikely to infect their loved ones, and at the same time, they may stop being seen as people who are likely to infect others, which will hopefully reduce stigma,” said Nelson Otwoma, coordinator of Kenya’s Network of People living with HIV/AIDS. “For HIV-negative partners, they will now feel less at risk if their partners start treatment early, and they will also feel safer trying to conceive children.”
Otwoma warned that counseling would need to be an integral part of any new policy to ensure people were well-informed of the remaining risks and the need to continue with other methods of HIV prevention such as condom use.
He also said in order for any policy to be developed, countries such as Kenya would need to step up the availability of CD4 testing technology and drastically increase the availability of ARVs to enable all those in need to access them.
AVAC’s Warren noted that implementing the results would go a long way towards achieving the goal of universal access to treatment, prevention and care. An estimated six million people around the world are on ARVs, but this is a fraction of the global need.
Finding the money
However, MSF’s Lynch noted that the recent retreat by major HIV donors could severely hinder plans to implement the study’s results.
“Unfortunately, the biggest donors globally seem to be shutting their eyes, ears and mouths when it comes to the evidence of what will work to lower infection rates and treat people living with HIV,” she said. “This study was sponsored by the US government – the US needs to listen to its scientists to inform their policies.
“With political will and the right policies, we can triple the number of people on treatment without tripling the costs,” she added. “When HIV treatment first started several years ago, the funding was not all available, but gradually, treatment programmes began; growth may be slow, but it will expand.”
A recent MSF report recommended ways of achieving increased treatment efficiency, including putting people on treatment earlier, decentralizing ARV provision to local clinics and empowering nurses to provide ARVs. The report further noted that because of funding problems, treatment programmes in several countries – including the Democratic Republic of Congo, Malawi, Uganda and Zimbabwe – were under threat.
According to Lynch, major donors were also backing away from committing to global HIV treatment targets. UN Secretary-General Ban Ki-moon recently outlined a new target to ensure HIV treatment for 13 million people by 2015.
“The large donors seem unsure about setting targets; it’s is a bit of a scandal, really. If 10 years since the first UN High Level Meeting on HIV we are not working towards targets, then the fight against HIV treatment and prevention is rudderless,” she said. “We are looking at a case of the best science and the worst policy.”