HIV: Treatment is the new prevention – and prevention works

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Prevention is the buzzword at the Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention(IAS 2011). Whether its the just-published results of the HPTN-052 trial in the NEJM, or the recently released data from two PrEP (Pre-exposure Prophylaxis) trials (Partners in PrEP and the TDF2 CDC PrEP trial), or indeed the already-published iPrEx trial of PrEP  and the CAPRISA tenofovir microbicide trial from last year, delegates seem energised by the news that antiretrovirals, whether used in therapy, preventive doses or in microbicides might combine, if deployed effectively, to tip the HIV epidemic into decline. The main findings are that early treatment can prevent transmission and that prophylactic treatment can prevent infection in men and women. One note of caution though: FEM-PreP was halted owing to a failure to show protection in at-risk women, so the good news is tempered by a need to interpret why this trial didn’t show a benefit.

Of course, ‘might’ is the keyword as there are many difficult choices ahead: who should be targeted for treatment or preventive therapy? Which combination of preventive measures will be most efficacious? How can we ensure access for preventives to people who cannot readily access healthcare facilities? What do we know about acceptability of different preventive measures: daily pills or a vaginal microbicide-laden ring? pills for the infected, the uninfected or both? What about issues surrounding women and whether its culturally acceptable for them to adopt some of the much-vaunted preventive measures? And, perhaps most importantly in specific regions such as Eastern Europe and Russia, or settings such as prisons, are these preventive measures also going to work for the IDU-fuelled HIV epidemic?

And lets not forget the cost. Treatment (let alone prevention) is still not available to all those in need — a shocking 9 million HIV-infected people worldwide are not in treatment. To fulfil the aim to get 15 million on treatment by 2015 all seem agreed we need more money, and of course, if preventives are widely adopted, the money needed for antiretroviral drugs is only likely to increase. Cash-strapped health ministers will need to understand not only the research evidence base but also the cost-effectiveness of different suites of preventive measures, and indeed the likely effectiveness of different combinations of HIV preventives, and treatments  in order to decide where to spend their monies.

Sadly, as MSF released the latest Untangling the web of ARV Price Reductions report its clear that whilst affordable medicines for HIV are likely to continue to be available in low income countries, some middle income countries including Brazil, India, Indonesia, Thailand, Viet Nam, Ukraine, and Colombia will now be penalised for improving economies through the withdrawl of key deals to provide cheap drugs. Similarly, although the Medicines Patent Pool were delighted to announce a deal with Gilead for licensing drugs for treatment of HIV and Hepatitis B, middle-income countries were left out of the deal. Bactrin Killingo of the International Treatment Preparedness Coalition called for attention to be paid to treating those in need — whether they be in high, middle or low income countries and pointed out that inequity means that a growing economy doesn’t always translate into better healthcare for individuals.  For many countries, compulsory licensing may now be a necessity.

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