Early HIV treatment plan 'game changer'

The early treatment of people with HIV massively reduces their infectiousness and gives the world its first real opportunity to halt the HIV epidemic. This follows results of a trial released in May which found that sex with an HIV-positive person on ARV treatment with an undetectable viral load is as safe as using condoms. Dr Francois Venter, head of the Southern African HIV Clinicians' Society, said this was the biggest news of the year.

He said that no other intervention beyond abstinence had shown such a level of protection and that it was probably even safer than condoms because things often went wrong with condoms. The trial has revolutionised HIV policy-making as, for the first time, ARVS are being counted as a weapon to prevent the spread of HIV as well as to treat the virus - what the experts are now calling treatment-as-prevention. The trial involved over 1 700 "discordant" couples, made up of an HIV-positive and an HIV-negative partner, and it was conducted in South Africa and eight other countries.

All the HIV-positive partners had CD4 counts of between 350 and 500, which meant that they did not yet need antiretroviral medication. The couples were randomly divided into two groups. In the first group, the HIV-positive partners were given ARVS immediately. In the second group, ARVS were delayed until the partners with HIV reached a CD4 count of 250 or developed an AIDS-related illness. The difference between the two groups, with over 800 couples in each, was striking. In Group One, only one person became HIV-infected but in Group Two, 27 people got HIV from their partners. Venter was on the Data Safety and Monitoring Board (DSMB) of the trial, which stopped the trial early because the results were so "unequivocal". He said the one HIV transmission in the first group meant there was a 96 percent reduction in transmission.

But even that one transmission was a weird one. It had happened right at the beginning of the trial, he said, indicating that the man was either already infected or that his partner had not yet reached a detectable viral load. Venter said that people who were on successful ARV treatment were 100 percent safe and would not transmit the virus. He said if all HIV-positive people started ARVS at CD4 350, this would have a massive effect on transmission. The one drawback of the study was that only three percent of participants were gay men, which is a group at high risk of HIV. Infectious diseases specialist Dr Kevin Rebe says the risk of HIV infection from anal sex is 18 times higher for the receptive partner than vaginal sex. Rebe, who runs the Ivan Toms Men's Clinic in Cape Town, said the highest risk groups needed to be represented adequately in studies. Meanwhile, the chief director for HIV/AIDS at the Health Department, Dr Thobile Mbengashe, has described the treatment-as-prevention as a "game changer". He said SA could hit the epidemic hard with a few proven interventions such as treatment-as-prevention that actually had a chance to halt the spread of HIV.

Health-e News Service - published in The Cape Argus, 29 November 2011
by:  Kerry Cullinan