Recent Headlines: A New Day for Treatment & Prevention
"We can now say that treatment is prevention. And that changes everything."
Mitchell Warren, AVAC, at IAS 2011
The past week of the 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2011) has felt like a watershed moment for the global response to HIV/AIDS. With new scientific evidence demonstrating that starting antiretroviral therapy (ART) early, pre-exposure prophylaxis (PrEP) and vaginal microbicides can all have an impact on HIV transmission, conversations are turning to how to implement and fund these approaches as part of a combination prevention package, not to mention the complexities of implementing this approach, including (but not limited to) sexual behavior and local epidemiology.
While this science has undoubtedly changed the landscape of HIV prevention, investment in biomedical intervention remained stable in 2010, according to a new report released at IAS2011. In order to start to understand the role funders can – and must – play to help capitalize on these scientific advances, we have attempted to provide a summary of recent news. The round-up is lengthy, but there’s even more out there (such as news on medical male circumcision protecting men from acquiring HIV via vaginal sex by as much as 76%, growing evidence that led National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci to be quoted as saying, “if circumcision was a vaccine, it would be approved tomorrow”). We also suggest visiting the IAS2011 Blog for additional commentary and information on related presentations.
Treatment as Prevention
Hailed as a breakthrough in HIV prevention, results from the HPTN 052 study run by the HIV Prevention Trials Network revealed that HIV-positive people who take combination antiretroviral therapy (ART) can reduce the risk of transmission to their HIV-negative partners by 96% (Los Angeles Times, 5/13). As the first study to show “a solid impact on preventing transmission to an HIV-negative partner,” (Agence France-Presse, 5/12), HPTN 052 raises “many questions about the public health impact of treatment…and the viability of a test and treat strategy,” (Science Speaks: HIV and TB News, 6/6). In fact, the impact of these results were overwhelming enough to convince an interim review panel to release the data four years in advance of the trial’s scheduled end (Wall Street Journal, 5/12). According to a statement from Fauci, "This new finding convincingly demonstrates that treating the infected individual – and doing so sooner rather than later – can have a major impact on reducing HIV transmission," (5/12). The Wall Street Journal also noted that as these results now provide evidence that treatment can function as prevention…“they may also diminish a bitter feud within the AIDS world over how much funding should go to treatment versus prevention.” It has also been suggested that this advancement may also work to reduce HIV/AIDS-related stigma, “if those who test positive can be put on drugs straight away to protect not only their own lives but also their partner's health,” (The Guardian, 5/13). In February China became the first country to incorporate Treatment as Prevention – which advocates for widespread HIV testing and access to treatment for all medically-eligible HIV-positive individuals - as part of its national HIV/AIDS strategy (BC-CfE Press Release, 2/24). A recent study of China’s AIDS response –recently commended by UNAIDS Executive Director Michel Sidibe - also found that they drastically reduced – by 60% - the death rate among PLWHA by providing access to free antiretrovirals (The Telegraph, 5/19). A pre-meeting session at IAS2011 was expected to feature new guidelines from the World Health Organization (WHO) on “HIV counseling and testing and access to antiretroviral therapy (ART) for sero-discordant couples – where one partner is HIV-infected and the other is not,” (Science Speaks: HIV & TB News, 7/18). Instead, the guidelines were highlighted as a “work in progress” in the context of confirming the efficacy of treatment as prevention and PrEP.
Advances in PrEP
More recently, results from the U.S. Centers for Disease Control and Prevention’s (CDC) TDF2 study and the Bill & Melinda Gates Foundation-supported Partner’s PrEP Study are the first to show that a daily oral dose of antiretrovirals (ARVs) used to treat HIV infection can reduce HIV transmission among uninfected individuals exposed to the virus through heterosexual sex (International AIDS Society Blog, 7/16). The TDF2 study, conducted in partnership with the Ministry of Health in Botswana, found that “a once-daily tablet of Truvada reduced the risk of HIV infection by roughly 63% overall in the study population of uninfected heterosexual men and women,” (CDC Press Release, 7/13). The University of Washington’s Partners PrEP study, conducted in Kenya and Uganda, found that two separate ARV regimens – tenofovir and Truvada – significantly reduced HIV transmission among serodiscordant couples,” (CDC, 7/13). The combined results of these two trials were welcomed after the April closure of the FEM-PrEP trial that was studying the effect of “once-daily Truvada versus placebo in preventing HIV infection among high-risk heterosexual, HIV-negative women in Kenya, South Africa and Tanzania,” (FHI, 4/18). According to the study results, use of Truvada provided no additional protection from HIV transmission, as compared to placebo. Some researchers speculate the result may have been due to lack of adherence (missing doses of medication) to the study regime (Washington Post, 7/13).
UNGASS and New Commitments in Vertical Transmission
At the conclusion of the June UN General Assembly Special Session on HIV/AIDS in New York City world leaders reconfirmed their commitment to the global response, and the UN Secretary-General Ban Ki-moon’s call to end the epidemic by 2012, by adopting the Political Declaration on HIV/AIDS: Intensifying our Efforts to eliminate HIV/AIDS. In a financial climate where the current estimated gap between total need and available resources for global HIV may be near $6 billion (Wall Street Journal, 6/9), countries have pledged to, among other things, support “the advancement of efforts towards reducing sexual transmission of HIV and halving HIV infection among people who inject drugs by 2015, in recognition that HIV prevention strategies inadequately focus on populations at higher risk—specifically men who have sex with men (MSM), people who inject drugs and sex workers…The Declaration also calls on countries to focus their response based on epidemiological and national contexts,” (UNAIDS Press Statement, 6/10). Leaders also agreed to a new global plan to push towards eliminating new HIV infections among children by 2015, and to protecting the health of their mothers. In response, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) announced an additional $75 million in funding for the prevention of mother-to-child-transmission (PMTCT), also known as vertical transmission. This funding will be on top of the approximately 300-plus million that PEPFAR already provides annually for PMTCT. In addition, several other partners pledged new commitments to help meet this bold new target: the Bill & Melinda Gates Foundation ($ 40 million), Chevron ($20 million) and Johnson & Johnson ($15 million) (UNICEF press release, 6/9). While the scale up of vertical transmission services have yielded an increase of ARV coverage from 15% in 2005 to 53% in 2009 among pregnant women living with HIV in low-and middle-income countries (A. Gupta, Huffington Post, 6/13), the recent full results of the PEPI-Malawi study have showed that extending daily doses of nevirapine to the HIV-exposed infant for the first six months of breastfeeding was safe and effective at reducing HIV infection, supporting the use of drugs for prevention (or prophylaxis) by the infant or mother throughout the duration of breastfeeding, up to two years,” (EGPAF Blog, 7/15).
Related News & Resources
1. To coincide with the opening of IAS 2011 The Lancet issued a special HIV/AIDS issue in which Dr. Julio Montaner makes a call to the international community to support the immediate and expanded roll-out of highly active antiretroviral therapy (HAART) under the Treatment as Prevention strategy. Also from IAS2011, abstracts for the HPTN 052 and CDC TDF2 trials are now available, with key data on treatment as prevention, early initiation of treatment and PrEP
2. The new declaration – We CAN End the AIDS Epidemic – created by international researchers and activists “points the way to the paradigm shift needed in the AIDS response.” It also references the principles outlined in the new investment framework from UNAIDS published recently in The Lancet.
3. NIH announces the largest single investment yet made into finding an HIV cure: $70 million over next five years to three research teams (7/11). For more information, watch this POZ video interview with Kevin Frost, CEO of amfAR, on the state of cure research. The “Rome Statement for an HIV Cure” was launched on 7/18 at IAS2011, calling for an acceleration of HIV cure research.
4. Watch the webcast from Kaiser Family Foundation’s May 25th briefing: How is the U.S. Global Health Initiative Changing What Happens in the Field? Also download related KFF documents: the recently updated FY2012 budget tracker: Status of U.S. Funding for Key Global Health Accounts; The U.S. Government's Global Health Policy Architecture: Structure, Programs and Funding; U.S. Funding for the Global Health Initiative (GHI): The President's FY 2012 Budget Request; and, The Women, Girls, and Gender Equality of the Global Health Initiative (GHI): Assessment of the GHI Plus Country Strategies. Read the great Science Speaks: Global HIV and TB News interview with Jen Kates, KFF Vice President and Director of Global Health and HIV Policy, on the future of GHI funding.
5. The WHO debuts first-ever guidelines on the prevention and treatment of HIV and other sexually transmitted infections for men who have sex with men (MSM) and transgender people. (The Global Forum on MSM & HIV, 6/21). In related news, a new global survey of more than 5,000 MSM has shown that less than half of MSM around the world have easy access to lifesaving HIV prevention and treatment services” (MSMGF, 7/21). In the U.S., Black MSM ages 18 to 44 are the target of a new federal campaign, “Know Where You Stand” currently being launched in 14 cities across the country. In June amfAR released the new issue brief: A New HIV Prevention Paradigm for Gay and Bisexual Men in the U.S. , and in May NASTAD launched a new resource in helping fight AIDS among gay Latino men.
6. How could the debt ceiling negotiations affect progress against HIV/AIDS? Read this POZ blog by AIDS Foundation of Chicago President & CEO David Munar. In other domestic funding news, as the ADAP waiting list surpasses 8,000, states continue to pull back on funding (Washington Post, 5/22). Read the recent ADAP editorial in The Lancet: Ensuring HIV Treatment for All in the USA.
7. Gilead agrees to first voluntary license deal with the Medicines Patent Pool. Under the agreement Gilead will share intellectual property on four of its AIDS drugs, allowing them to be made by generic drug companies (7/12).
8. Watch this movie trailer about PEPFAR-supported achievements in vertical transmission.