The “test-and-treat” strategy to stop HIV/AIDS – providing universal access to treatment to reduce new infections – seems to be gaining momentum at the XVIII International AIDS Conference in Vienna.
“Treatment as prevention is a promising strategy that needs to be properly evaluated in clinical trials,” Dr. Bernard Hirschel of the Infectious Diseases Service Geneva University Hospitals in Switzerland, said at the plenary talk today.
It is known that decreased viral load lowers the risk of HIV transmission and that effective treatment lowers viral load to undetectable levels, he said.
Therefore, if one could identify and treat all people living with HIV/AIDS, the epidemic would wither and die away, Hirschel said.
But he admitted this was a “pipe dream” and called for clinical trials to be set up to test the preventive potential of ART.
The “test-and-treat approach is unlikely to be scaled up without clear evidence that it works, he indicated.
Researchers from France and South Africa intend to test “everyone in at least 30 South African regions” in a five-year study starting this year, according to a report by Bloomberg.
“In half the regions, they’ll start treatment immediately for those who test positive. In the other half, they’ll wait until the patients’ immune systems deteriorate to a certain level,” Bloomberg reports, quoting Hirschel.
New infections have fallen in some cities as treatment expands, some studies have shown, including results from Canada in the Lancet this week.
Moreover research on transmission risks in couples where one partner is HIV-positive and the other HIV-negative, known as sero-discordant couples, suggests that treatment protects against infection.
“Funding agencies are currently evaluating proposals for more definitive studies, where a number of communities are randomized to receive the “test-and-treat” approach, or continue as before,” the IAS conference media centre reports.
Meanwhile, international agencies at the conference warn that donor funding for antiretrovirals may be running short.
Michel Kazatchkine of the Global Fund to Fight AIDS, TB and Malaria said donations from European countries to the fund dropped in 2008-2009 by $600 million, and the fund has an estimated shortfall of $4 billion to $6bn.
In 2004 I visited a needle exchange programme on the outskirts of Bangkok, in Thailand, that aimed to prevent the spread of HIV. Former drug users were running it and their results were impressive.
But, as new research shows, such initiatives are the exception globally.
Very few injecting drugs users get access to these services, a report in Lancet this week reveals.
“Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low.
“There is an urgent need to improve coverage of these services in this at-risk population,” Dr Bradley Mathers and his co-authors conclude, after reviewing a number of studies published from 2004 onwards.
They found: “By 2009, National Syringe Programmes had been implemented in 82 countries and Opiod Substitution Therapy in 70 countries; both interventions were available in 66 countries.
“Regional and national coverage varied substantially.”
“Sub-Saharan Africa (0·1 needle—syringes per IDU per year) had the lowest rates of syringe-needle distribution,” they reported.
UNAIDS estimates that around 30 per cent of HIV transmission outside sub-Saharan Africa is driven by unsafe injecting practices, Reuters reports.
A new Ugandan study offers great hope for people with AIDS in rural areas in Africa needing antiretroviral treatment.
The trial tested a model in which lay-trained counsellors, not doctors or nurses, treated people at home – and they were as healthy as the patients being treated in clinics.
The cluster randomised trial took place in 44 areas in Jinja, Uganda.
The results, published in the Lancet journal online this week, suggested: “This home-based HIV-care strategy is as effective as is a clinic-based strategy.
“(This) could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care.”
The researchers found after two and a half years that:
*Home-based ART by trained lay workers achieved equal health gains;
*Reduced mortality, hospital admission and viral supression were used to measure health gains;
*Patient costs were cut by half or more in the home-based care;
*Home-based care cost the health service slightly less.
Supporting the model, an editorial in Lancet stated: “This result provides compelling evidence for rolling out home-based ART to complement facility-based delivery and facilitate access.
“(This is true) especially in rural settings with weak health systems, shortage of clinical staff , and poor patients for whom transport cost and lost work-time provide obstacles to treatment initiation and adherence.”
The results are exciting but Uganda has one huge advantage over South Africa. Stigma around HIV/AID is far less prevalent and people are much more open about having the virus.
South Africa’s Health Minister Dr Aaron Motsoaledi is proving to be a responsible leader like his predecessor Barbara Hogan.
In marked contrast to previous health ministers, he responded soberly, and not defensively, to six major Lancet papers published online today, on the critical state of South Africa’s health.
Motsoaledi told The New York Times: “We do take responsibility for what has happened and responsibility for how we move forward.”
The health minister, who took control in May, also promised to try to prevent mother-to-child HIV transmission.
He confirmed this commitment at a maternal, neo-natal, child and women health summit in Johannesburg today, when he said he would take its recommendations on reducing child mortality and the death of mothers very seriously, and act on them as soon as possible.
His willingness to listen to doctors, nurses and scientists is hugely significant, given the history of conflict between those at the frontline and those in power.
South Africa will lose 2,5 million people unless antiretroviral treatment is urgently scaled up, Professor Linda-Gail Bekker says.
She is the chairperson of the 4th SA Aids conference – under the banner Scaling up for success – and was opening the conference.
“This is an epidemic of unprecedented proportions. We are in the red zone in Southern Africa,” Bekker said, pointing to a map illustrating how bad it is.
Bekker, deputy director of UCT’s Desmond Tutu HIV Centre, said the conference was intended to identify:
* scientific evidence of what works and how to scale it up;
* the priorities;
* the next steps;
* how to remove obstacles; and
* how to work together with every sector.
So that’s what I’ll be looking out for.
“I’m on the scale up and start to role numbers back (campaign),” she said, demonstrating how HIV could disappear from the map. “Yes, we can.”
Dr John Hargrove from SACEMA (which does epidemiological modelling) gave a sweeping overview of why Southern Africa has been worst hit by the epidemic.
He looked at migratory patterns, medical male circumcision, religion (Muslim countries are less at risk), women’s education levels, the spatial influences on HIV infection and the disruption of families.
When it comes to spatial influences, HIV spreads much slower in communities where people sleep only with other residents, “with their neighbours wives only, rather than with their neighbours wives most of the year and 10% with random” partners. With the 10% random partners thrown in, the infection rate explodes.
Another issue he tackled was that of HIV spreading along trucking routes. But he said: “The problem is not roads but (Cecil John) Rhodes”, explaining how forcing men into migrant mine labour had disastrous consequences for families.
He also expanded on the Lancet debate of treatment as a way to end the epidemic.
“Use ARVs as an offensive weapon to kill the epidemic not just as a defensive (weapon),” he said, advocating early treatment for people living with HIV, especially the youth.
“I want to throw away the CD4 count machine,” he commented, explaining that if everyone was tested once a year voluntarily and treated without delay “that would kill the epidemic by 2010″.
Other keynote speakers Emeritus Archbishop Desmond Tutu and Luyanda Ngcobo also made powerful statements but that report is in The Times tomorrow.
Deputy President Baleke Mbete replaced Health Minister Barbara Hogan as the final speaker, much to the disappointment of Hogan’s supporters.
She is expected to close the conference on Friday. Till tomorrow.