July 29, 2011
In last week's post, I previewed the International AIDS Conference in Rome. This week I'd like to offer some brief reflections on the activity there, and what it means for our PEPFAR programs.
For those of us who have been working in this field for some time -- which in my case is about 30 years -- the mood in Rome was positive, with a palpable sense of encouragement. This was largely fueled by two things: new evidence of the long-term benefits of antiretroviral treatment efforts to date, and new scientific breakthroughs regarding the benefits of treatment for prevention. These developments are transforming the way we think about AIDS.
HIV/AIDS has had a devastating impact on life expectancy in many African countries, and in turn on their economic and social development. As an editorial in the Annals of Internal Medicine recently noted: "Political debate centers on whether, especially given the current global economic downturn, money designated for HIV treatment in Africa would be better spent in [other] areas. ... But often forgotten in these debates is the unique nature of AIDS as a killer of young adults, of those on whom the very survival of societies depends."
That's why a new study published in the Annals of Internal Medicine last week is so encouraging. The study examined the long-term impact of the growing availability of treatment with antiretroviral drugs (ARVs) on life expectancy in patients of a Uganda NGO. The authors found that treatment "increased life expectancy to nearly normal levels," noting that this finding "underscores the fact that HIV diagnosis in resource-limited settings is no longer a death sentence."
We have long known that treatment is a life-saver; the impact of this on the lifespan of the individual on treatment -- and ultimately on society -- is now increasingly clear. Also becoming clear are the dramatic prevention benefits of treatment -- saving not only the lives of the people taking the medicines, but the lives of their partners as well.
Data presented in Rome demonstrated the definitive prevention benefits of treatment. HIV-positive individuals who were part of HIV-discordant couples were randomly assigned to either early treatment or treatment that was delayed until they had clinically declined. Among couples where the infected partners received early treatment, transmission to the uninfected partner was reduced by at least 96 percent. This was an extraordinarily powerful result. It is consistent with the well-established fact that with ARVs, HIV-positive pregnant women can nearly eliminate the risk of passing HIV on to their newborns.
In addition to the preventive effect of treatment, two studies demonstrated the impact of oral antiretroviral pre-exposure prophylaxis (PreP) on transmission. One was a Gates Foundation-funded study among HIV-discordant heterosexual couples in Kenya and Uganda, and another was supported by the U.S. Centers for Disease Control and Prevention among heterosexual men and women in Botswana. Both found over 60% fewer new infections among those taking PreP.
These new data add to our knowledge base from studies on topical PrEP among women (a 39% reduction in new infections) and oral PrEP among MSM (a 44% reduction). Taken as a whole, the evidence base for the preventive effect of antiretroviral treatment is now unequivocal. ARV-based tools could be critical for the many people in HIV-discordant relationships and for others who are otherwise at high risk of infection.
Clearly there will be implications of these findings for PEPFAR, and it is important to prepare our programs to incorporate this new research in a careful but rapid way. Many in Rome expressed the view that the U.S. must play a leadership role in this effort, and we are doing so.
Our task is to translate new science into policy to inform programs. To do this, we are working with the World Health Organization and others as they develop normative guidance for the potential use of these tools. We are also supporting critical implementation science research needed for future scale-up of related programs.
Earlier this year, PEPFAR established a distinguished external Scientific Advisory Board. We are working closely with its members to assess the key issues around scale-up of these tools. Some of the big issues we will face include: increasing testing; supporting overburdened providers and health systems; ensuring linkages to care; prioritizing resources; and targeting the right populations. We are fortunate that in recent years we have had the experience of translating research on male circumcision into programs, providing us with valuable lessons as we move forward.
It is apparent that this is an extraordinary moment in the global AIDS fight, and particularly for PEPFAR -- a moment in which a path toward an HIV-free generation is becoming clear. Just as America's support has been essential in so many of the breakthroughs to date, both in terms of scientific research and program implementation, we will continue to be a global leader in this next stage of the fight.