Conference co-chair, Julio Montaner, at the Opening Session of IAS 2015, with a Native blanket received as a gift. Photo ©Steve Forrest/Workers' Photos/IAS

Leading figures in the HIV response have endorsed a call for immediate access to antiretroviral therapy for all people upon diagnosis with HIV, on the opening day of the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in Vancouver, Canada.

The Vancouver Consensus Statement has been endorsed by leaders of major agencies including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), and is intended to place pressure on donors and governments to support expanded HIV treatment and prevention.

The statement calls for immediate access to antiretrovirals and for access to pre-exposure prophylaxis (PrEP) for those at high risk of HIV exposure, and urges rapid progress towards the implementation of new scientific evidence.

Professor Chris Beyrer of Johns Hopkins University told delegates, “Let this be the conference where the question of when to start treatment stops being a scientific question and starts being a question of finance and political will.”

Image from presentation given by Dr Meg Doherty of the WHO Department of HIV/AIDS at IAS 2015.

The World Health Organization (WHO) will issue new HIV treatment guidelines later this year, recommending treatment for everyone living with HIV, regardless of CD4 count.

The new recommendation follows results from two large randomised trials, START and Temprano, released in 2015, which both showed that starting treatment at a CD4 count about 500 cells/mm³ resulted in less serious illness and AIDS-related deaths than deferring treatment.

The new guidelines will recommend:

• Treatment for all adults and adolescents living with HIV, regardless of CD4 count, prioritising those with CD4 counts below 350 cells/mm³ and those with AIDS-defining illnesses.
• Treatment for all children living with HIV.
• Treatment for all pregnant women living with HIV, not just during pregnancy, but to continue lifelong (Option B+).
• Pre-exposure prophylaxis (PrEP) should be offered as an additional prevention option for people at substantial risk of HIV.

The new guidelines support the UNAIDS 90-90-90 target (see below), but will present a major challenge for some countries, in terms of healthcare and treatment provision.

Michel Sidibé, executive director of UNAIDS, speaking at the International HIV Treatment as Prevention Workshop. Image by www.treatmentaspreventionworkshop.org

Some of the first data to come from large studies in Africa examining the population impact of HIV treatment as prevention approaches suggest that the objectives of testing and treating 90% of those eligible can be achieved.

These encouraging findings were presented to the International HIV Treatment as Prevention Workshop in Vancouver on Saturday. Michel Sidibé, executive director of UNAIDS told the workshop that his organisation’s ambitious targets of having 90% of people tested, 90% of people with HIV treated and 90% of those on treatment with a suppressed viral load were achievable – so long as there is political commitment and leadership.

Several very large randomised studies are examining the population impact of scaling up ‘test and treat’ approaches in African countries. The ultimate aim is to substantially lower new HIV infections (incidence). It’s too early to have those results, but researchers reported that the large SEARCH study in Kenya and Uganda is meeting the 90-90-90 targets, and another large study is close to meeting these targets.

Some of the successful interventions described include running health campaigns offering testing for high blood pressure, diabetes and malaria as well as HIV; offering home-based HIV testing; streamlining services so clinic and pharmacy visits are less frequent and waiting times are reduced; improved training for staff; and dealing with adherence and attendance problems in a more empathetic way.

Health services in some countries in Africa, including Botswana, Malawi and Rwanda are now providing effective HIV treatment to a greater proportion of their HIV-positive citizens than the United States and other rich countries.

However, researchers also highlighted the issue of inequalities in care access, with prevalence remaining higher in key populations including female sex workers and men who have sex with men. Without appropriate services, adapted for these groups and others who face barriers to care, they and their sexual partners will not get the benefits of HIV treatment.

Cheryl Johnson, World Health Organization, presenting at IAS 2015. Photo by Liz Highleyman, hivandhepatitis.com

The World Health Organization (WHO) launched new guidance on HIV testing at the conference.

The guidance urges people planning HIV testing programmes to make careful, strategic choices about which HIV testing interventions will be best able to reach individuals with undiagnosed HIV. This requires careful assessment of HIV prevalence in different groups, current uptake of testing services, available resources, cost-effectiveness and the preferences of people needing to access testing.

In addition to recommending that routine HIV testing in medical settings should be expanded to reach new groups of people, the new guidance also recommends more HIV testing by non-medical ‘lay providers’, often in community settings.

Self-testing for HIV (sometimes known as home testing) is not yet recommended because the evidence base for its effectiveness and the best ways to provide it is still emerging. However, it was discussed at length during the launch of the guidance, and may have an important place in future guidance.

In order to achieve the ambitious 90-90-90 targets (see article above), improvements in HIV testing services will be needed. Many countries are lagging further behind on the target of diagnosing 90% of people living with HIV than on the other two targets.

For the first time, WHO has recommended a larger role for lay providers in HIV testing. Lay providers are people who do not have a formal medical education, but who have been trained to deliver specific health services. Allowing lay providers could help ease workforce shortages and allow peer-to-peer HIV testing services to be provided. This can improve the uptake of HIV testing in key populations such as men who have sex with men, sex workers, and people who inject drugs. However, many countries will need to change their policies which currently restrict testing to medical professionals.

Panel on hepatitis treatment access. Photo by Liz Highleyman, hivandhepatitis.com

The development of effective new interferon-free treatment makes it possible to cure more than 90% of people with chronic hepatitis C, including most people with HIV and hepatitis C virus (HCV) co-infection, researchers said at the 2nd International HIV/Viral Hepatitis Co-infection Meeting, preceding the IAS conference.

Looking at hepatitis B, antiviral therapy can effectively suppress the virus long-term, but most people are still not cured.

Expanding access to expensive hepatitis C treatments has become a key issue in the field as the challenge of developing highly effective and well-tolerated therapy has been largely solved.

While there is a growing consensus that everyone with hepatitis C can benefit from treatment regardless of stage of liver disease, some daunting barriers remain, including the high cost of treatment.

In addition, a large proportion of people with hepatitis B or C around the world have not been diagnosed, and countries often do not have a good understanding of the extent of their viral hepatitis public health problems.