A Game Changer in HIV Prevention, Care, and Treatment

A Game Changer in HIV Prevention, Care, and Treatment

Yesterday the results of HIV Prevention Trials Network (HPTN) 052, a clinical trial funded by the National Institutes for Health, offered definitive proof of what we have long suspected---that treating HIV infected persons substantially reduces the risk of transmitting HIV to uninfected persons.

This is FANTASTIC news and offers very convincing evidence that, at least for heterosexual discordant couples (the study was not able to enroll significant numbers of gay men), if the infected person is on ART, the uninfected partner is protected. And more broadly, it offers significant evidence that treatment is indeed highly effective in preventing transmission of HIV. This can reasonably be described as a “game changer” with respect to how we think about HIV prevention, care, and treatment. We used to talk about “treatment as prevention,” but now we can say “treatment IS prevention.”

Read the UNAIDS report here.

The study took place in nine countries and followed randomly assigned couples (one of whom was HIV positive and the other HIV negative) to either one of two study groups. In the first group, the HIV-infected partner immediately began taking a combination of three antiretroviral drugs. In the second group (the deferred group), the HIV-infected partners began antiretroviral therapy (ART) when their CD4 counts fell below 250 cells/mm³ or an AIDS-related event per guidelines.

There were a total of 39 cases of HIV infection among the previously uninfected partners. Of those, 28 were linked through genetic analysis to the HIV-infected partner as the source of infection (in the other 11 cases, the uninfected partner was either infected by someone else, or the results are still pending). Of the 28 linked infections, 27 infections occurred among the 877 couples in which the HIV-infected partner did not begin antiretroviral therapy immediately. Only one case of HIV infection occurred among those couples where the HIV-infected partner began immediate antiretroviral therapy. This finding was statistically significant and means that earlier initiation of antiretrovirals led to a 96% reduction in HIV transmission to the HIV-uninfected partner.

Until now, we have relied primarily on condoms, behavior change, clean needles and a safe blood supply as the primary prevention approaches, now we can safely state that ART treatment for infected persons is absolutely effective in reducing HIV transmission.

There was evidence presented last year in the Lancet from British Columbia that showed the rate of new infections in the entire province declined after a policy of widespread HIV testing and early treatment was adopted, but this is the first randomized clinical trial, the gold standard, to show this for certain.

Although there are certainly difficulties in rolling out expanded treatment in many global health projects around the world, primarily due to much increased costs associated with earlier treatment, I think there will be many opportunities in the near term to think creatively about how to expand our programming to incorporate these exciting new developments.

For myself, I look forward to figuring out how to transform this exciting news into effective programming.

Scott Kellerman, MD, MPH is a Principal Technical Advisor for HIV at Management Sciences for Health