International Analysis: Prevention via Treatment

Op-Ed By Julio Montaner

≈The Mark News≈

The rate of new HIV infections has decreased dramatically in the past decade, but millions of people who are infected remain untreated. Pioneering HIV/AIDS researcher Julio Montaner argues that if those people get the treatment they need, transmission of the virus can be stopped.

The medical community already has the drug treatments required to virtually eliminate HIV/AIDS worldwide within a generation. Sadly, that appears unlikely to happen because we don’t have the resources to identify those infected with HIV and apply these treatments before they transmit the virus on to others.

Traditionally, medical science has confronted epidemic diseases with a two-pronged strategy: Discover a cure for those already sick, and a vaccine to prevent new cases. Unfortunately, HIV is a complex virus and, after more than 25 years of research, we have neither a cure nor an effective vaccine. The search must continue, as these tools are essential if we are ever going to eradicate this disease that has killed approximately 35 million people worldwide.

In the meantime, existing treatments could dramatically change the course of the epidemic.

Up until the mid-1990s, an HIV diagnosis was tantamount to a death sentence. The earliest single-drug therapies proved inadequate in stemming the progress of the disease.

In 1994, working with a group of international collaborators, my colleagues and I in Vancouver, Canada began to study a novel triple combination therapy regimen. The results were remarkable. By December 1995, to our surprise and beyond our expectations, we found that the three-drug therapy was able to drive the levels of HIV in blood down to undetectable levels. A study in the United States showed similar results, and eventually it was proven that sustained undetectable levels of HIV in blood are key to arresting the progression of the HIV disease.

At the same time, we noticed an unanticipated and rather significant decrease in the number of new HIV diagnoses. It appeared that this highly active antiretroviral therapy (HAART) was also making it less likely that a person living with HIV would transmit the virus.

In 2011, the results of a major study conducted in 13 countries by the U.S. National Institutes of Health provided compelling and definitive evidence regarding the efficacy of HIV treatment as prevention. Immediate use of HIV treatment was associated with a 41 percent decrease in morbidity and mortality, and a 96 percent reduction in HIV transmission.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has endorsed the Treatment as Prevention strategy since 2010. In early 2011, China became the first country to adopt it as a nationwide strategy. More recently, the World Health Organization formally incorporated it in the 2013 Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection, and the United States has identified it as key to achieving an AIDS-free generation.

Despite this progress, less than one-third of people living with HIV are on life-saving HIV medications. We need to move beyond the false economy of saving on HIV testing and HAART use, as it fuels disease and new infections, markedly expanding the AIDS mortgage we will leave behind to the next generation.

Several independent studies clearly show that the more we test and the sooner we treat, the more we prevent in terms of new HIV infections, disease progression to AIDS, and premature death.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria has set a goal of raising US$15 billion for the 2014–2016 period. Last month, the U.K. pledged more than $1.5 billion, adding to the $5 billion pledged by the United States, $1.4 billion pledged by France, and $750 million pledged by Nordic countries, among other pledges.

This is a great start. But to reverse the advance of HIV, we must ramp up and fully roll out Treatment as Prevention everywhere. We have the means to prevent death, prevent morbidity, and stop transmission. The promise of an AIDS-free generation is real. What we need is for governments to act now.

Julio Montaner, MD, FRCPC, FCCP, is Clinical Director of the BC Centre for Excellence in HIV/AIDS and Professor of Medicine, University of British Columbia, in Vancouver, Canada. Dr. Montaner is a former president of the International AIDS Society and remains an elected member of the IAS’s Council. He was given the Frederic Newton Gisborne Starr Award by the Canadian Medical Association in 2013.

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