'Treatment as prevention' dominated IAS 2011. In fact, the chair of the first satellite session was the first to update us to 'treatment is prevention', citing the premature closing of two trials in the week leading up to the conference as proof positive that we have indeed entered a new era where medical prevention must be taken seriously.
Both trials the chair was referring to were for Pre-Exposure Prophylaxis (PrEP).
One conducted in Botswana, the TDF2 study; and the other, Partners PrEP, in Kenya and Uganda. And both showed remarkably similar conclusions. If taken daily by sexually active heterosexuals (TDF2) or the negative partner in a serodiscordant heterosexual relationship (Partners PrEP) tenofovir (TDF) alone or Truvada (TDF+FTC) prevents the acquisition of HIV by between 62% and 73%.
Last year, another PrEP trial, iPrEx, showed a 42% reduction in the risk of HIV infection amongst negative gay men and transsexuals who took a once-daily dose of Truvada.
There was also excitement around microbicides. The CAPRISA trial, also reported last year, showed that a vaginal gel containing 1% tenofovir applied before and after sex reduces the likelihood of women getting HIV by 39%.
But the biggest billing at the Rome conference most certainly went to HPTN 052 – a study that showed how treating the person with the HIV in a serodiscordant heterosexual relationship reduced the likelihood of them transmitting it to their partner by 96%.
HPTN 052 also showed that earlier treatment (between counts of 350 and 500 CD4s) greatly reduced the likelihood of HIV-related clinical events. Currently, the level in many developing countries at which treatment is recommended is 250; and this trial, along with others yet to be announced, highlights the importance of intervention at earlier levels.
On the surface it seems quite simple: treat everyone with HIV (and those at risk of getting it) and we’ll be right.
Of course it’s not that simple.
INDIVIDUALS OVER PUBLIC HEALTH
The idea of a universal ‘test and treat’ policy, where everyone who tests positive is put on treatment, has obvious flaws.
Wafaa El-Sadr, Director of the International Center for AIDS Care and Treatment Programs in New York, raised adherence as the key issue in her talk.
We all know the importance of adherence to keep ARV drug levels at a point where resistant strains cannot develop. It’s for this very reason that no one starts antiretroviral therapy until they are ready to take the pills every day. Treating doctors and support organisations understand this and put considerable energy into preparing us for therapy.
Professor El-Sadr observed in various studies how adherence drops over time and called for interventions to be put in place to ensure that people are not only provided with treatment but are supported to adhere to it.
And any coercion to treat, regardless of how good intentioned, is not an option.
Eric Fleutelot, a French community advocate from Sidaction, made this elegantly clear in the same session.
"No one should be forced to be treated without their consent or coerced into starting ART for public health over the health of the individual," he said.
He believes, as do many, that ARV’s preventative qualities are secondary to their therapeutic benefit.
This 'prevention revolution' he believes provides instead an opportunity to give power back to people living with HIV.
But there are other challenges that need addressing. Removing the stigma that still exists is a priority, Fleutelot stressed.
Stigma makes it harder for people to disclose, hinders testing efforts and further marginalises those most at risk (injecting drug users and gay men, in particular).
He also raised the chilling prospect of how these new data could be used to further criminalise those who transmit HIV if they are not on treatment.
Professor El-Sadr also pointed out how many people still do not know they have the disease. Even in developed countries, like the US and Australia, between 10% and 20% of those with HIV are unaware of the fact.
This group are some of the key unsuspecting drivers of the epidemic and therefore efforts around testing and the barriers to it must be faced before we see any significant drop in rates.
A key aspect of keeping those of us with HIV less infectious, is maintaining an undetectable viral load. This requires adherence to an appropriate suppressive ARV regimen and frequent testing for and treatment of any other STIs.
A surprising statistic was found in one session slide entitled ‘The Spectrum of Engagement in HIV Care in the USA’. From an estimated total of 1.2 million people living with HIV in the USA, the authors broke down the numbers, showing how only just more than 200,000 (19%) have, in fact, undetectable viral loads.
Julio Montaner from the University of British Columbia and a man coined 'The King of HAART’ took a firm line in the same session, calling on governments to prioritise treatment as prevention and for us to strike a balance between benefit to the individual and benefit to society.
"The evidence is in," he said. "Treatment is prevention. Treatment dramatically prevents morbidity and mortality. Furthermore, treatment prevents HIV transmission in vertical, sexual and injection drug use settings. The challenge remains to optimise the impact of this valuable intervention. Failure to do so is not an option."
BUT AT WHAT PRICE?
So, how are we going to pay for all these drugs?
To their credit, Gilead Sciences, who make tenofovir, have been the first pharmaceutical company to sign on to the Medicines Patent Pool, a Swiss-based organisation dedicated to expediting ART globally. Set up by UNITAID last year, the Pool will act as third-party negotiator between pharmaceutical companies and those who make lower-cost generic versions of their drugs.
Unlike the pirating system that currently operates, this system recognises the intellectual property of those who have developed the agent.
But concerns have already been raised regarding how these lower-priced generics are to be run out. The Pool is focused on low-income countries only, excluding those like Brazil who are regarded as lower/middle, despite their high population of really poor PLHIV.
The aim must be affordable supply for everyone, regardless of their country of origin. And this was acknowledged, in theory at least, by those at the conference.
An indication of how the cost of a tab of Truvada, for example, varies depending on where it is being marketed was flashed on screen during a presentation by Tim Farley, a scientist with the World Health Organisation. While many high-income countries, are paying around $23 per tablet, he showed by just how much the cost drops, using generic versions, to 12c per tab for those in the developing world.
Gilead’s agreement to share their recipes for tenofovir and their four other ARVs adds hope to the United Nations brave promise to treat 15 million PLHIV by 2015.
The pressure is on for other companies to come to the party. Some have been playing hard ball and prompted one particularly colourful protest at the conference.
Gus Cairns, from NAM, the UK community-based HIV treatment information service, believes that one of the fundamental problems with biomedical interventions aimed at negative people is that, by and large, people without a medical condition are not that much interested in taking treatments.
But involvement of community is imperative, he said, in running out any prevention strategy.
Cairns cited one example where community was not involved, notably, a PrEP trial protest at the AIDS Conference in Bangkok 2004, when those the trial aimed to serve took exception to being excluded from how it was being run out.
This clash between activists, academics and the research community highlighted the poor communication between stakeholders and the need for mutual understanding of values.
The concept of ‘community’ was touted often at IAS 2011.
Sometimes it felt like those of us who belong to this group are some homogenous mass that can be easily represented, spoken for and corralled into doing things because they are good for us.
I’m sure this is not really the case but I did feel for the lone advocates on the panels of mainly scientists who had to speak for all of the‘community’. Like researchers and clinicians from identical disciplines who often disagree on minutiae, we too do not speak with one voice.
Cairns used the New York City Health Department’s much maligned ‘It’s Never Just HIV’ campaign to illustrate how a prevention campaign can divide a community. The now notorious ads received both condemnation and praise at the time they were released.
Communities are not always right, either, he noted. And provided a stunning example of just how wrong a community organisation can get it when trying to instil the safe-sex message.
The ‘HIV is a mass murderer’ campaign commissioned by Regenbogen, a German community HIV prevention organisation, received universal condemnation for stigmatising those with HIV by depicting the virus as Adolf Hitler.
TOWARDS AN HIV CURE
The other big news from Rome was the official launch at the conference of research into scientific strategies for finding a ‘functional’ cure for HIV.
Recent advances have led scientists to believe that this once elusive dream is now worthy of serious attention.
Citing the Berlin patient as a proof of concept that eradication of HIV from an individual is a possibility, Nobel prize-winning virologist and IAS president-elect, Professor Françoise Barré-Sinoussi, also cautioned that this technique would never be possible on a large scale.
(Timothy Brown, the ‘Berlin patient’, received a bone marrow transplant from a donor who had a genetic immunity to HIV, and to date he has had no viral rebound.)
Barré-Sinoussi referred instead to elite controllers and their ability to naturally control HIV as being one of the keys to unlocking the puzzle.
Another is in the recent vaccine research into newly discovered neutralising antibodies. It is time we accelerated research into reservoir research, she said.
Rowena Johnston from Amfar, the US research organisation founded by Elizabeth Taylor, commented how proud their patron would be, knowing of these renewed efforts.
Mark Harrington of the Treatment Action Group raised community participation as key to furthering advances into cure research. He acknowledged the thousands of PLHIV who put themselves on the line in the past to bring us the HAART we have today.
Some of this research may be dangerous, he said, with invasive interventions. But we cannot progress without people with HIV willing to volunteer and put themselves through the trials.
I felt brave and a little cheeky at this point and asked the panel about their timeline?
Unprepared to make the same mistakes vaccine researchers have done before them, they were understandably reluctant to reply.
"Within our lifetime," was the best answer I could get.
Conference photos courtesy IAS, top to bottom:
- Community advocate, Eric Fleutelot, at a session on 'Treatment as prevention'
- A protester and entourage stormed the media centre during the conference, calling on pharmaceutical companies to join the Medicines Patent Pool
- Women's 'Prevention Revolution' demonstration
- 'Towards an HIV cure' press conference with Françoise Barré-Sinoussi (2nd on left) and Rowena Johnston and Mark Harrington (far right)