Changing My Mind on Treatment as Prevention

Treatment Cascade: A Spotlight Series

This article first appeared on PositiveLite.com, Canada's Online HIV Magazine.

One hundred and eighty degree turns happen in a variety of ways. Sometimes we seize the steering wheel of our lives and in one fell swoop travel along an opposite path. Other times, we take the turn slowly, one degree at a time, gradually realizing the path we are on leads nowhere and we need to go off in radically new directions. That's been the case with my realizing that most of my once fervently held objections to treatment as prevention, in 2013, make much less sense than they once did.

Why? In the last decade, our knowledge of disease progression has changed as has how much we know about the impact of antiretroviral treatment (ART) on our ability to transmit the virus. But treatments have changed too, and so has my own willingness to look at both sides of the argument, to weigh them against each other and to make informed choices which recognize, above all, a shifting environment.

As well, the realist in me tells me that when it comes to HIV prevention, the status quo isn't working. I respect those who work in the prevention community. But, to be blunt, those who continue to play with the same old tricks -- plugging condom use when we know the limits to their efficacy in real life situations, trying to effect behavioral change with the odd stray missile thrown at the social determinants of health -- are playing in the wrong sandbox. Let's not fool ourselves. None of these things will stop the epidemic. We need new tools.

Enter my new friend, treatment as prevention.

Bob Leahy

Accepting it as a valid, in fact necessary, tool hasn't been a slam dunk. My early introduction to it left me decidedly unimpressed. At the Canadian AIDS Society (CAS) eight years ago I echoed the concerns of the Quebec caucus who first brought the issue of treatment as prevention to the floor, concerned at the notion of people being put on treatment without informed consent and with no demonstrable benefit to their health. If memory serves me I moved a motion that was approved at a CAS annual general meeting condemning treatment as prevention -- and in fact was instrumental in drafting a highly critical position paper when I was subsequently elected to the CAS board.

Fast forward a few years. I was still a treatment as prevention doubter in January 2012 when, through my work for PositiveLite.com, I nervously picked up the phone to talk with Dr. Julio Montaner, the distinguished former head of the International AIDS Society, now heading the British Columbia Centre for Excellence in HIV/AIDS. Montaner is of course a leading expert on, and advocate for, treatment as prevention. His arguments, though, have not persuaded all in the HIV/AIDS movement, notably many people living with HIV/AIDS.

Going in to that long conversation with Montaner, which you can read in two parts here and here, I had real reservations as to whether treatment as prevention was ethical or even good for people living with HIV, yet alone effective. I'll get to how I've processed those issues since, but let me first say a few words about Montaner.

As I said in my interview, he's a passionate man. One to one, he speaks with excitement born of frustration. But the thing that impressed me most was how so much of our conversation was rooted in his obvious burning sense of justice, of civil rights, of the conviction he has of what is the right thing to do. Far from down treading on patients' rights, for instance, he was vocal and insistent about the need for informed consent and hugely concerned about disparities in access to treatment and care.

He's also very persuasive, both in his manner and in his arguments. More of that later.

In any event, I wanted to look at the commonly used arguments against treatment as prevention, ones which I once upheld, and share why there has been a shift in my appraisal of them since those early days at CAS. Beginning with ...

1. Let's not start treatment earlier than we absolutely have to ...

There is an oft expressed concern, or was, that HIV treatments are toxic. If this is true, why expose the body to HIV meds longer than necessary? Montaner makes the point that while not perfect, treatments have improved considerably. More important, he suggests most everybody will need to start treatment sooner or later; delaying a few years until the immune system is showing signs of collapse results in a only a few year's respite from meds out of what will almost certainly be many decades of treatment. Blunt words, but I found that argument quite persuasive.

2. There is no demonstrable benefit to the patient to starting treatment early.

There was always the belief, now the certainty since HPTN052 (CATIE dubbed it "the trial that changed everything"), that antiretrovirals could have a marked impact in reducing one's ability to transmit the virus. Experts now believe that benefit can, in the right circumstances, be as effective as condom use. That's powerful. But whether there are any other benefits has been a thorny subject. The evidence now seems to firmly suggest there are. The negative impact of inflammation for instance, even when CD4 counts are holding strong, has been well documented. As CATIE's James Wilton said to me in a recent interview:

More and more research is showing that even early on in the course of HIV infection the virus can begin to cause long-lasting and permanent changes to certain organs and the way the immune system works. Research is also showing that uncontrolled HIV replication causes ongoing inflammation which may lead to premature aging of the immune system and accelerated development of age-related conditions such as cardiovascular disease.

The bottom line? Others may, but I'm not prepared to ignore the evidence that, simply put, starting treatment early really is better for us.

3. But what about side effects if I have to start treatment now?

When I started advocating against treatment as prevention at CAS, going on treatment was full of problems for many. It's way less problematic now. In fact many who've started on one-pill-a-day treatments such as Atripla, a particularly well-tolerated medication, will answer "what side effects?" But the fact is, if you are going to experience them (and I hope you won't), that's not likely to change whether you start treatment now or later.

4. But what about long-term side effects? Those treatments may look safe now, but side effects can often emerge over the longer term. Why encounter that prospect earlier than you might need to?

This is a variation on 1. above and for many years, I felt it to be a very persuasive argument. After all, I suffer from both lipodystrophy and peripheral neuropathy, the latter very badly, consequences of talking medications whose latent side effects came as a surprise to all. So yes, I know side effects can happen downstream. But this argument is not so much an argument against treatment as prevention as treatment in general. So while I don't discount this argument entirely, I've learned to put my faith in the fact that modern-day meds are better than those that have caused myself and others grief in the past. And, you know, sometimes, as throughout the history of HIV treatment, we just have to take a chance, recognizing that few things in life are certain.

5. People are going to be given treatment against their will because someone decides it's best for them.

First of all, suggesting treatment be offered for a condition not long after diagnosis is hardly exclusive to HIV -- think cancer -- and there are always dangers inherent in this process. Informed consent is the issue as is the opportunity for coercion. It's tricky to ensure informed consent happens always, but certainly not insurmountable -- and that's where we can and must do the work. CATIE's James Wilton says:

It's important that people living with HIV have constructive and meaningful discussions with their healthcare provider before they make the decision to start treatment. These discussions need to explore their readiness to start treatment, the risks and benefits of initiating treatment and what the evidence does, and does not, tell us. Ultimately the decision needs to rest with the person living with HIV. The tools we need are those that support the doctor-patient relationship to ensure informed decision-making and treatment readiness. CATIE has developed several of these tools, such as an HIV treatment talking tool (Your Doc Talk), treatment videos ("Starting HIV treatment: Personal Stories"), A Practical Guide to HIV Drug Treatment, and workshops.