November 27, 2012
Recent advancements in our understanding of HIV transmission, treatment, prevention and testing are changing the landscape of our response to HIV and generating a significant amount of optimism. The buzz at the International AIDS Conference this past July in Washington D.C. was that we may now be able to achieve an "AIDS-free generation" where first, no one will be born with the virus; second, that as people age, they will be at a far lower risk of becoming infected than they are today; and third, that if they do acquire HIV, they will get treatment that keeps them healthy and prevents them from transmitting the virus to others.
Similarly, the United Nations AIDS organization's "Getting to Zero" campaign for World AIDS Day, December 1, signifies the aim of getting to zero new infections, zero AIDS-related deaths, and zero discrimination.
There are many reasons why we should feel these commendable goals can be achieved. But there are also significant challenges that need to be addressed before we get there.
First, a word about those things that give us confidence.
We now have newer medications for people living with HIV that are easier to take and have fewer side-effects, thereby making HIV treatment more manageable. These medications also allow people living with HIV to have a near-normal life expectancy. We also have a much better understanding of the importance of starting treatment earlier in order to achieve better health outcomes.
Treatment can also help prevent the transmission of HIV. Research shows that people living with the virus who are on successful antiretroviral therapy and have a fully suppressed (undetectable) viral load are less likely to pass HIV on to others.
Due to these advancements in our understanding of the virus, treatment guidelines now recommend that people living with HIV begin antiretroviral therapy as soon as they are ready after diagnosis.
To complement the uptake of early treatment, we have also made progress in developing new testing technologies and strategies that allow us to detect HIV earlier and faster than ever before, allowing HIV-positive people to learn about their status much sooner after becoming infected.
Early diagnosis is crucial to our success in preventing HIV transmission for three major reasons. First, it may help identify people during the first few months after HIV infection when their viral load and risk of HIV transmission is at an all-time high. Second, it gives newly diagnosed individuals the option to start treatment earlier. And lastly, the majority of people diagnosed with HIV take active measures to reduce their risk of passing HIV on to others.
Although condoms and clean needles are the backbone of our prevention efforts, we are learning about additional prevention tools that can also be used. We now know that the same drugs used to treat HIV can be used by HIV-negative people to help reduce their risk of an HIV infection. These preventative approaches are known as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). While PEP is the standard of care for occupational exposure to HIV, its availability for non-occupational exposures and its cost vary greatly across Canada. Although PrEP is not currently approved for use by Health Canada, some doctors may already be prescribing it to their patients (known as "off-label" use).These new prevention approaches are promising options for HIV-negative people who are at a high risk of getting HIV.
HIV drugs, in combination with other strategies such as not breastfeeding can also help eliminate the transmission of the virus from an HIV-positive mother to her newborn child.
Despite these advancements, translating them into a generation without AIDS or without new HIV infections remains challenging. The hurdles we continue to face include limited financial resources applied to HIV prevention and treatment, and the barriers people living with and at-risk of HIV face when accessing HIV-related services.
Additionally, people living with HIV can be criminally prosecuted for not disclosing their HIV status to their sexual partners, which can discourage them from wanting to know their status, and thereby opting out of getting tested.
Stigma, discrimination, and poverty can make it difficult for marginalized populations to access services, which explains why some populations are more strongly affected by the HIV epidemic. The reality is that a number of Canada's communities have a high prevalence of HIV. According to the latest estimates (2008) by the Public Health Agency of Canada, gay men and other men who have sex with men represent a majority (51 per cent) of people living with HIV. People who use injection drugs represent 20 per cent, people from regions where HIV is endemic (such as Africa and the Caribbean) represent 14 per cent, and Aboriginal people represent eight per cent of the total HIV epidemic in Canada.
It's clearer than ever that HIV prevention, testing, care and support, and treatment are all mutually reinforcing elements of an effective response to realizing an "AIDS-free generation." At CATIE, we feel these advancements call for an "integrated approach" to HIV treatment and prevention. Such an approach will be discussed, for example, in September, 2013, when CATIE will host a forum that will explore the recent developments in HIV and determine ways to integrate HIV treatment and prevention for us to move forward in an effective way.
While we are still years away from an "AIDS free generation," we appear to be on the right path. It only takes a look back 30 years ago at the despair we once felt in the face of this unknown disease to see how far we've come.
Laurie Edmiston is the executive director of CATIE.