Use of Antivirals in Prevention: Current Challenges and Controversies. 18/7/11

For the first time in the 30 years of the HIV epidemic, we now have conclusive evidence that earlier treatment initiation in HIV-positive people can also reduce risk of HIV transmission

IAS 2011

Even amidst the celebratory spirit last year in Vienna with the release of the CAPRISA 004 results, thinking about an end to this epidemic in our lifetimes seemed no more than a pipe dream. But building momentum since last year’s conference, we’ve seen the iPrEx results in November and more recently the landmark data from the HPTN 052 trial announced in May and presented at IAS 2011. And just last week two additional studies – the Partners PrEP and TDF2 studies – provided further data about effectiveness of PrEP.

For the first time in the 30 years of the HIV epidemic, we now have conclusive evidence that earlier treatment initiation in HIV-positive people can also reduce risk of HIV transmission—and that use of ARVs in HIV-negative people can reduce risk of infection.

We can now say that treatment is prevention. And that changes everything.

The last fifteen years have brought more than 30 drugs to treat HIV, and in the last decade we’ve seen complicated drug cocktails reduced to as little as a pill a day. Better yet, we’ve proven that with sustained community mobilization, strategic financial investments and a little ingenuity, HIV treatment programmes can be rolled out anywhere and everywhere.

Getting to this point hasn’t been easy. Science is difficult and successes have been hard won and often seem to have taken far too long. Implementing successful programmes for treatment and prevention is challenging, but time and again the global community of advocates, scientists and policy makers has risen to the challenge.

Making sure we have the money and the political will to end this epidemic should be the easy part. But it isn’t, especially when promising scientific advances come at the same time as enormous economic challenge.

Policy and funding for AIDS has consistently fallen short. We’ve made great strides in rolling out treatment programmes in developing countries, but millions of HIV-positive people are still in need of drugs that can save their own lives and help break the cycle of new infections. We know that people who are marginalized from society are often at greatest risk of HIV infection, yet it is impossible in many communities and countries for gay men, transgendered people, injecting drug users, sex workers, and others at high risk for HIV infection to access existing treatment and prevention programmes.

Since the HPTN 052 result, a diverse group of international researchers and activists have come together to release a declaration – We CAN End the AIDS Epidemic – that points the way to the paradigm shift that is needed in the AIDS response. This declaration embraces the principles outlined in the new investment framework from UNAIDS published recently in The Lancet – principles that point to a targeted and strategic approach to investment in the prevention AND treatment response that will yield long-term dividends.

Now what? We have an opportunity – and a responsibility – to act on scientific evidence that points the way to ending this epidemic. There are enormous challenges in translating this vision into reality that will take even greater political and financial commitment than ever before. The next steps will not be simple, but they will be essential. Scientific data do not change the world – programmes and policies backed by civil society, donors, implementers and governments do.

We can save lives now AND save money in the long run by funding evidence-based strategies with combination ART as a cornerstone of a set of proven strategies to prevent and treat HIV. These include male and female condoms; male circumcision; prevention of vertical transmission; behavior change programmes that target social norms as well as individual risk; activities addressing key populations including sex workers, gay men and other men who have sex with men and transgender people; harm reduction programmes for injecting drug users; and sustained investment in research and innovation for the future.

The evidence is in. The path forward is clear. We know the way to end AIDS for all time. Now is the time to invest and act accordingly.