A large international study using antiretroviral drugs
(ARVs) as a prevention method has closed four years early because it has found
that giving ARVs to HIV-positive people reduced the chance of them infecting
their partner by 96% (see News in brief for more details).1
The result of the HPTN 052 study puts the results of other
HIV prevention trials in the shade. In recent years we’ve seen three trials
showing that men who get circumcised are about 65%
less likely to acquire HIV;2,3 that prescribing daily Truvada (combined tenofovir and FTC) pills
as pre-exposure prophylaxis (PrEP) to HIV-negative gay men reduced
their risk of acquiring HIV by 42%;4 that giving women a microbicide
gel containing tenofovir to use during sex reduced
their risk by 39%;5 and even that, to everyone’s surprise, an
HIV vaccine few thought would work reduced
infections by 31%.6
All promising results, but not ones you’d want to base an
entire HIV prevention strategy on. A twentyfold reduction in risk, on the other
hand, is the sort of epidemic-halting result we’d like to see in a vaccine. And
of course the great thing about the HPTN 052 concept is, as activists pointed
out, that it’s almost “prevention for free”: many people who could be taking
ARVs as a prevention method should be taking them as treatment anyway, or would
be pretty soon. The fact that there was an 82% reduction in TB cases in
positive partners who took early treatment underlines this. Buy treatment, get
prevention thrown in.
All very exciting, although not entirely unexpected. More
than a year ago, in February 2010, the Partners
in Prevention study, which was designed to find out if treating herpes
might reduce HIV transmission, found that the minority of its participants who
started taking ARVs were 92% less likely to transmit HIV to their partners once
they started therapy.7
So does HPTN 052 imply that, given these huge reductions in
transmission, we should regard ARV treatment as essentially the answer to the HIV epidemic? No, for
a number of reasons.
Firstly, we are having a hard enough time getting ARVs to
people who need them as vital treatment. Currently just over 50% of diagnosed people in the world with a CD4
count below the old World Health Organization threshold of 200 cells/mm3
are getting them, and roughly a third of people with CD4 counts below the new
threshold of 350 cells/mm3.8 Some people think it may be
unaffordable to put more HIV-positive people on ARVs in order to reduce the
risk of them infecting others, when their health would be okay for several
years without taking them. We need some good cost-effectiveness studies to find
out if the prevention bonus of putting more people on ARVs would justify the
cost in the long run.
Secondly, although people have got the impression HPTN 052
was a solely heterosexual study, they did manage to recruit 38 gay couples, or
3% of the total. But that is not nearly enough to establish whether the same
reduction in risk applies to gay men and, while we suspect it does, we still
need the studies to provide data to convince doubters. The same applies to
injecting drug users.
Thirdly, there was the sneaky fact that there were another
eleven HIV infections in the study that came from people other than the primary
partner (that’s 27%
– an almost identical proportion to the 28% seen in
Partners in Prevention). People ‘play away’, and, in many parts of the world,
the main way HIV is transmitted is through casual sex, often from people who
don’t know they have HIV.
This reminds us that you can put every diagnosed person in
the world on ARVs, but if you don’t drive testing and diagnosis rates up to the
point where the undiagnosed are a small minority, HIV will continue to be
passed on.
For ‘treatment as prevention’ to start really working
worldwide, we need to: increase rates of testing; reduce the proportion of
undiagnosed people to a minimum; link the diagnosed to care; provide them with
ARVs; support them to take them; and monitor their health to ensure they remain
virally suppressed.
If any one of these six links in the chain is weak, the proportion
of people with HIV who are virtually non-infectious due to ARVs will be a
minority. Even in San Francisco,
a city which is starting to provide evidence in the form of reduced diagnoses
that treatment as prevention might work, the proportion of HIV-positive people
in the city who are on ARVs and have viral loads below 50 copies/ml is less
than 50%.9
So, people will say, what about good old-fashioned safer
sex, and getting people to use condoms? After all, the absolute lowest-possible
price of combination therapy in low-income countries (which involves regimens
including the toxic d4T) is about $90 a year,10 whereas the price
for one condom a day for 365 days, as supplied to donor programmes, would be
about $9.11
This would be fine, if people used condoms consistently. But
although determined programmes have increased the rate of condom use in casual
sex in many countries to well over 50%, it seems pretty impossible to get
long-established partners to use them.12 Condoms remain part of the
answer, but if they were the whole answer, the epidemic would have finished by
now. We probably have no alternative but to start using ARV drugs as prevention
much more systematically.