“This is an extraordinary moment in the AIDS epidemic – we finally have the tools to turn the tide,” said Diane Havlir, MD, of the University of California San Francisco, speaking to the arsenal of HIV prevention interventions the AIDS community now has at its disposal to combat new infections worldwide. She spoke alongside a team of other HIV experts to an audience on Capitol Hill Wednesday, supporting the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program’s reliance on scientific evidence to drive its work to end AIDS.
A key player in driving down new infections will be scaling up antiretroviral treatment because of is benefits to the individual and the community – preserving health, economic productivity and child development, and preventing new HIV infections in children and adults, said Havlir, a member of the Scientific Advisory Committee of the Center for Global Health Policy. The HIV Prevention Trials Network (HPTN) 052 trial recently demonstrated that HIV-infected persons on antiretroviral therapy (ART) were 96 percent less likely to sexually transmit HIV to their uninfected partners than those who were not receiving treatment. The study also found a 40 percent reduction in progression to AIDS, incidence of tuberculosis (TB), and death among those who received immediate ART.
This is a huge win overall, given that TB is the biggest killer of people living with HIV, she said.
The United Nations estimates millions of lives have been saved over the last few years thanks to ART, Havlir said, noting an economic model that predicts a 95 percent reduction in new HIV cases in ten years with implementation of annual HIV testing and treatment for all.
Dr. Havlir is working with the government and others in Uganda to do a testing and treating campaign as part of a comprehensive prevention approach. “In this rural western district, we tested for HIV but also other diseases with the goal of looking at overall community health,” and not singling out and stigmatizing HIV, she said. They used finger-prick tests on 1,000 community members per day testing for HIV (CD4 and RNA viral load), malaria, TB, hypertension and diabetes, meanwhile distributing bed nets, condoms, and deworming kits.
We found eight percent HIV prevalence, 28 percent hypertension, and three percent diabetes – and we followed up with linking these people to care, Havlir said. “HIV can be a platform not only to combat our own epidemic but also other communicable and non-communicable diseases.”
In 2010 there were 390,000 new HIV infections in children globally, representing one of every seven infections in the world, said RJ Simonds, MD, of the Elizabeth Glaser Pediatric AIDS Foundation, another speaker at the Hill briefing. More than 90 percent of these are transmitted from mother-to-child, or vertically. More than half of HIV infections in Africa are among women, and Africa bears the brunt of pediatric infections in the world. In 2010 there were 1.5 million HIV positive pregnant women, more than 90 percent of whom were in Africa.
Prevention of mother-to-child transmission (PMTCT) scale up in the U.S. led to a greater than 95 percent reduction of pediatric AIDS cases, said Dr. Simonds. Scale up in other parts of the world was not so quick, but since that time PMTCT programs expanded globally to include the short-course antiretroviral research success, the introduction of PMTCT-Plus initiatives that keep mothers on ART for life, and steadily increasing coverage of ARV prophylaxis and treatment for pregnant women, he said. As examples of this expansion, Simonds said by 2009 53 percent of HIV-positive pregnant women in low-resource countries had access to PMTCT, and the PEPFAR program averted 200,000 pediatric HIV infections in 2011 through PMTCT programs.
Voluntary Medical Male Circumcision
Three randomized controlled demonstrated that medical male circumcision (MC) is more than 60 percent effective at preventing transmission of HIV during vaginal sex as compared to a man who is not circumcised, and the benefit lasts over time. Experts argue you can’t leave it out of any successful campaign to end AIDS.
Renee Ridzon, MD, agrees.
“Medical male circumcision (MC) is a one-time intervention making this extremely different than other prevention modalities,” such as pre-exposure prophylaxis and even condoms, where adherence is a real problem, said Ridzon, who works with The Bill & Melinda Gates Foundation. That’s why this intervention is more akin to a vaccine, she said.
As a human, she’s excited about its potential to save lives, she said. But is it safe? In PEPFAR programs, they see adverse events in less than two percent of their patients, none of which are serious in nature, thanks to intense training and experience.
What is more, MC saves money over time. Ridzon reviewed economic modeling data showing that if you scale up MC to cover 80 percent of 18 to 49 year olds in the 14 target countries in sub-Saharan Africa (which have a high HIV prevalence, a low rate of MC and a predominantly heterosexual epidemic), you could save $16 billion by 2025 and prevent millions of HIV infections in men and women.
But 20.3 million MCs are needed to turn the tide on the epidemic in these countries.
That’s a lot of MCs, Ridzon said, but keep in mind that PEPFAR did 40 million HIV tests last year. PEPFAR is a big program. Break it up by countries, and communities, and it can be done, she said, and the men are coming. “Demand is tricky business, which requires community education and involvement,” Ridzon said, noting that in Zimbabwe they even have a national rap star promoting MC.
Ridzon then spoke briefly about MC device innovation, which many hope will expedite the procedure, require fewer physicians, and make the operation safer and more cost effective. The devices are catching headlines of late, including an article in this week’s New York Times, which highlights the Shang Ring and the PrePex devices in particular. MC devices ideally should not require anesthesia, sutures, or a sterile setting, which is not the case for these two popular candidates, Ridzon said. So there is still work to be done in this area.
Prevention in marginalized HIV-risk populations
Many populations that are at high-risk for HIV face stigma and other barriers to care and treatment from the government and society, said Chris Beyrer of the Johns Hopkins School of Public Health. For example, in PEPFAR programs, only four out of every 100 HIV-infected injection drug users (IDU) have access to ART. He showed a map of the world with countries whose HIV incidence is expanding colored in red – mostly Eastern European countries where IDU is the most common cause of HIV infection.
Beyrer also highlighted the epidemic among men who have sex with men (MSM), where the HIV burden is high, growing and disproportionate, he said.
Scientists have examined using different combinations of prevention interventions that would make the most sense in these high-risk populations to find out which would be most beneficial.
In Peru, for example, researchers found that providing a combination prevention toolkit for all MSM including condoms provision, behavior change communication, and ART access for all HIV infected MSM, would steadily start to decrease new infections in as little as four years. Beyrer also cited a study from 2010 among IDU in Ukraine, where providing a combination of opioid substitution therapy, clean needles and syringes, and antiretroviral therapy to the HIV infected could reduce relative HIV incidence by 40 percent.
Some of these interventions are very cost effective, Beyer said, giving syringe exchange as an example. It just requires the buy in and support of governments and stakeholders. Finding the optimal combination of prevention interventions – as well as care and treatment activities – in a given community to maximally reduce new infections is key, he said. “We can’t end the epidemic or see our way to an AIDS free generation if we don’t respond to the needs of these groups.”