February 23, 2011
Since the initial presentations on and consequent controversies surrounding the subject, I have been an avid supporter of the principles behind the ground-breaking concept of 'Treatment as Prevention.'
The premise of 'Treatment as Prevention' is as follows: people living with HIV who adhere to an antiretroviral therapy regimen almost always achieve undetectable viral loads -- the amount of virus in a body fluid such as blood, semen or vaginal secretions -- at certain stages of their treatment. When the viral load is undetectable, the risk of HIV transmission is significantly reduced.
With this in mind, achieving universal access to anti-retroviral drugs becomes doubly important, as treating all those in need, and earlier, not only saves individual lives but actually lowers the collective viral load of communities, significantly reducing rates of HIV transmission. At the end of last year, the Institute of Medicine issued a very timely report titled, "Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility." I welcome the publication of such a report and its call on the United States and African nations to move toward a strategy of shared responsibility for the HIV response. The proposals on aid effectiveness and increased national ownership in, and contribution to, HIV prevention, treatment and care programmes are totally in line with IAS policies. At the same time, I want to use the opportunity to emphasize the key role that effective treatment plays in effective prevention.
One focus of the report is on the urgent need to ramp up prevention efforts in Sub-Saharan Africa, highlighting the fact that the number of HIV/AIDS cases are expected to significantly outpace treatment resources by 2020. African nations, already faced with treatment shortages, will be confronted with increasingly difficult choices about how to allocate inadequate supplies of lifesaving antiretroviral therapy (ART).
As a medical professional in Uganda, I have witnessed first hand the consequences of such treatment shortages and am in no doubt that, unless current donor retreat and waning political interest are properly addressed, such shortages will become increasingly and frustratingly common.
Of particular concern for me here is the insufficient acknowledgement in the report of the disastrous effect that treatment cuts could have also on preventions efforts. By dealing with "treatment" and "prevention" as two disconnected efforts, the report does not sufficiently recognize vital evidence that expanding ART coverage has preventative benefits for the entire community. By relegating the push for expanded treatment coverage to second place due to economic shortfalls, the fact that ART coverage is actually one of our most powerful preventative tools is overlooked.
I point to one example of a case study from Uganda -- a study in which investigators estimated that their treatment interventions reduced new HIV infections by approximately 90% over three years- to reinforce that all prevention driven efforts, in Sub-Saharan Africa and elsewhere, should include a comprehensive treatment coverage programme. Based on viral load and transmission data from a study in Rakai, Uganda, a US Centers for Disease Control-led Home Based AIDS Care (HBAC) study showed that HIV transmission can be drastically reduced when HIV-positive individuals are treated, their partners undergo counselling and testing, and the HIV-positive partner receives adherence support to maintain an undetectable viral load.
Expanding ART coverage in a community has huge benefits. Not only does it significantly lower the rate of HIV transmission, it also decreases levels of tuberculosis, decreases the number of orphans, and preserves and strengthens Health Systems.
However, if governments, donors and policy makers are ever to be convinced of the multiple benefits of expanded ART coverage, all of us working in the HIV field must refrain from using unhelpful dichotomies to describe treatment and prevention efforts. I urge the international community to stop asking themselves and each other whether it is more important to invest in HIV prevention or in HIV treatment, and to accept the compelling evidence we have before us: that HIV treatment IS HIV prevention, and that the path forward must include an increase of resources for ART coverage.
By Elly Katabira, International AIDS Society President.