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Lancet Article - Ending the AIDS epidemic

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Mark Platt
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Posts: 290
Lancet Article - Ending the AIDS epidemic
Posted on: August 4 2014, 10:34 am

I'm posting this because it's an interesting take on the role that TasP might play in the future.
By Richard Horton
See: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61256-3/fulltext

There are some articles journal editors will wish they hadn't brought to public attention. But there will also be papers they are immensely grateful to have published. One such Lancet paper is Julio Montaner's truly landmark 2006 viewpoint entitled, rather modestly now looking back, “The case for expanding access to highly active antiretroviral therapy [HAART] to curb the growth of the HIV epidemic”. The paper began by charting, since its inception in 1996, the rise and impact of HAART. Montaner and his team went on to hypothesise that, “A prevention-centred approach would therefore argue that treating 100% of HIV-infected individuals at once could greatly reduce HIV transmission.”

The idea of treatment as prevention (TasP) was born. The concept was quickly proven in 2011 with publication of the HPTN 052 trial, in which immediate treatment with ART reduced HIV transmission events by 96%. It's hard to recall what a struggle it was to get ART taken seriously. In 2003, Jim Kim, now President of the World Bank but then an adviser to the late Director-General of WHO, Lee Jong-wook, led an initiative called “3 by 5”. Many critics thought getting 3 million people living with HIV onto ART by 2005 a crazy idea.

I remember one WHO adviser at the time asserting that an entire generation in Africa would have to be sacrificed because treatment was an impossible dream. True, the target wasn't met, but the goal galvanised the global community to be much more ambitious. How different the story is today. UNAIDS reported this month that 12·9 million people were receiving ART globally by the end of 2013. UNAIDS has now set new goals—90—90—90: by 2020, 90% of people living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will be taking ART, and 90% of those receiving ART will have viral suppression. UNAIDS reports that, “Modelling demonstrates that achieving these targets by 2020 will enable us to end the AIDS epidemic by 2030”. That is some promise. So what next?

The urgent challenge is to identify ways to reach these 90—90—90 goals, to define the knowledge we need to do so, and to address dangers we might be missing in our enthusiasm to scale-up treatment. Last week's International AIDS Conference, held in Melbourne, Australia, was a moment to pause and think hard about these questions. Julio Montaner emphasised the power of ART not only to lengthen life (there is a direct correlation between mortality and ART coverage), but also to lengthen productive life—e.g., in gainful employment. A direct relation also exists between ART coverage and new HIV infections—further evidence for the effect of treatment as prevention.

The momentum is now very firmly in the direction of more liberal use of ART. “Test and Treat” is the ultimate possibility, but the evidence is not yet available to make this policy a definitive international recommendation. The best that can be said now lies within the latest WHO guidelines, which recommend treatment when CD4 counts fall below or equal to 500 cells per μL. Treatment as prevention is now increasingly being adopted in national HIV/AIDS policies—this year alone, in Spain, Panama, Sierra Leone, and South Africa (a country that, as Quarraisha Abdool Karim pointed out, is home to 17% of the global HIV-positive population). We are at a turning point in the history of this epidemic.

But what about the dangers. TasP is no magic bullet. Implementation requires reaching key affected populations. It will demand widespread diagnostic testing. It will necessitate defeating stigma and discrimination. It will require good adherence to medication. Nukshinaro Ao, from the International Community of Women Living with HIV, emphasised the challenge for rural areas where there are few reliable clinical services. Edwin Bernard, from the HIV Justice Network, gave an even sterner warning: TasP must not become coercive.

There are already signs that some countries (Uganda, Botswana, and Greece) might use the science of TasP to enforce mandatory testing and forced treatment. Unrestrained advocacy for TasP might conjure up fear that people living with HIV are a public health risk to be controlled. Writing in 2006, Montaner and his colleagues concluded that, “The present approach to the management of HIV/AIDS is clearly not sustainable”. The challenge for the next 5 years is to ensure that rolling out TasP does not trigger a similar warning.
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