NAM aidsmap

International AIDS Society President, Elly Katabira ©IAS/Marcus Rose/Worker's Photos

Excitement has greeted the opening of the International AIDS Society Conference in Rome.

Over 5000 delegates have gathered for the three-day conference where the use of HIV treatment as prevention looks set to dominate discussions.

“We have witnessed two years of significant biomedical advances, the likes of which we have not seen since the antiretroviral breakthroughs of the mid-1990s,” said Elly Katabira, President of the International AIDS Society.

“The excitement around these advances in research – whether they be the CAPRISA 004 vaginal gel, the HPTN 052 study on treatment as prevention, talk around the path towards a cure, or the encouraging signs on PrEP and vaccines – is very much driving the debates and discussions that we are going to see in Rome over the next few days.”

In May, results from a trial of antiretroviral treatment taken by the HIV-positive partners in couples where one partner was uninfected showed that treatment reduced the risk of the HIV-negative partner becoming infected by 96%.

Partly because of these findings, the United Nations has set a target of treating 15 million people with antiretroviral drugs by 2015.

Last week, two studies showed that pre-exposure prophylaxis (PrEP) reduced the risk of infection with HIV by up to 78%.

However, delegates have been cautioned that efforts will be needed to ensure that the impressive results of clinical trials are replicated in routine care.

UNAIDS Executive Director Michel Sidibé said: “Sceptics are saying that expanding treatment is risky and unsustainable. What is truly risky, truly unsustainable, is waiting for treatment.”

There remain concerns about the funding of the global response: “We pay now, or we pay forever!” said Sidibé.

Prof. Myron Cohen, University of North Carolina ©IAS/Marcus Rose/Worker's Photos

Policy makers need to think how the use of antiretroviral therapy, PrEP and microbicides can be used in an HIV prevention package, delegates to the Rome conference have been told.

The strong message at a conference satellite meeting was that antiretroviral prevention methods are not in competition with each other.

Delegates were discussing the rapidly changing landscape of HIV prevention methods that use antiretroviral drugs.

Using the right prevention technology to suit the needs of the individual emerged as a theme of the meeting.

“Is treatment always the best option [as the prevention measure] in the serodiscordant couple? If the index partner can’t or won’t take pills, or if the HIV-negative partner is having concurrent partners, they might need PrEP or a microbicide,” said Professor Myron Cohen of the University of North Carolina, who was a leading researcher in the study that showed early treatment reduced the risk of transmission to an HIV-negative partner by 96%.

Engaging at-risk populations was highlighted as a major challenge.

“We need to reach out to women who don’t perceive themselves to be at risk, and we should be getting communities to rally round to be early adopters of tenofovir [microbicide] gel,” said Samu Dube of the Global Campaign for Microbicides.

Samu Dube, Global Campaign for Microbicides ©IAS/Marcus Rose/Worker's Photos

There was also concern that more work needs to be done with service providers to convince them that they have a role in expanding the awareness of at-risk individuals of the treatment-based prevention methods that are becoming available.

“Providers can be major gatekeepers,” said Catherine Hankins of UNAIDS.

It will be necessary to identify the best way to use the new treatment-as-prevention products, the meeting was told.

Equally important will be the development of strategies to overcome social, legal and health-system barriers that could reduce the impact of the technologies.

Research is needed to see how effective the different approaches to using HIV treatment in prevention are in specific communities and epidemiological settings, a satellite meeting held on the opening day of the conference heard.

The meeting, organised by AVAC and the European AIDS Treatment Group, emphasised the importance of implementation research – identifying barriers to the implementation of prevention interventions and developing strategies to overcome them.

Investigators suggested that no single treatment-as-prevention intervention was “best,” nor that there was an ideal package of interventions – rather a flexible approach was needed that responded to local conditions.

However, data were presented showing that starting HIV therapy early would be the most effective option if resources were limited.

But late diagnosis rates mean that wider use of antiretroviral therapy would not achieve the 96% reduction in infections seen in the HPTN 052 trial.

Even a 60% reduction in transmissions would be dependent on: 60% of people being diagnosed within a year of infection; 90% of these individuals taking therapy; 87% achieving an undetectable viral load within six months; and 99% remaining on treatment.

Nevertheless, the meeting heard that a combination approach would be more resilient to real-life situations.

The next wave of prevention trials needs to examine the use of treatment in service settings, said Sheena McCormack of the UK’s Medical Research Council. She identified finding out the acceptability of PrEP among target populations such as gay men, and how to make interventions cost-effective, as two priorities.