The unsung revolution
OPINION: The decade’s most important development in HIV science has gone largely unnoticed in the South African media. By Rebecca Hodes
For the first time in the thirty-year history of the global HIV epidemic, there is now conclusive evidence that initiating antiretroviral treatment at an earlier stage in disease progression can prevent HIV transmission as well as improve the health of people living with HIV.
The international study (referred to as ‘HPTN 052’), enrolled 1,763 sero-discordant couples, in which one partner was HIV-positive and the other HIV-negative. The study was conducted across seven countries and three continents (Africa, Asia and South America). Participants were assigned randomly into one of two groups. In the first group, HIV-positive partners received antiretroviral treatment at an earlier stage in their disease progression, when their CD4 count was between 350 ‘ 550 cells/mm3. In the second group, HIV-positive partners received antiretroviral treatment at a later stage, when their CD4 counts had dropped below 250 cells/mm3, or they had experienced an AIDS-defining illness. Intensive counseling, including HIV prevention information, condoms and testing was provided to all participants for the course of the study.
A preliminary review of the study’s results by the data and safety monitoring board, an independent group of experts that advises study investigators, found that the benefits of early initiation of antiretroviral treatment were so conclusive that all participants in the study should be offered immediate antiretroviral treatment. HIV-positive partners on antiretroviral treatment had a 96% reduction in transmitting HIV to their HIV-negative partners if they started treatment earlier, at a CD4 count of between 350 ‘ 500, compared to trial participants who initiated treatment at a CD4 count of 250 and below.
The study also found that participants who received antiretroviral treatment immediately experienced further clinical benefits compared to those in the deferred treatment arm. There was a significant reduction in their incidence of extrapulmonary tuberculosis ‘ 17 cases among participants who had started antiretroviral treatment earlier versus 3 cases among participants who had initiated treatment later.
These ground-breaking results were presented at the recent International AIDS Society conference in Rome. The response of clinicians and activists was jubilant ‘ with spontaneous celebrations breaking out in the corridors of the conference venue. Clinicians and scientists have long believed that antiretroviral treatment may reduce HIV transmission, with many HIV prevention programmes using antiretrovirals as a mainstay since the late 1990s. These include programmes to prevent the transmission of HIV from mother to child, and post-exposure prophylaxis interventions for rape survivors and healthcare workers to prevent HIV ‘sero-conversion’ after a potential infection.
Why is this study so important, and what are its implications for South Africa? The global financial crisis precipitated a backlash against funding for antiretroviral treatment programmes. Numerous major international donors have reduced their funding of antiretroviral treatment programmes in South Africa, partly because of a belief that the costs of antiretroviral treatment outweighs its benefits, and that scarce money for public health is better spent elsewhere.
This thinking chimes with widespread, reactionary beliefs about the alleged harms of antiretroviral drugs. These include unfounded claims of how antiretroviral drugs benefit only those who take them, when in fact the drugs benefit societies at large through preventing new HIV infections and improving the health outcomes of those living with HIV (and, by extension, their families and communities).
Another misconception regarding antiretrovirals is that they help to spread HIV by extending the lifespan of those living with the virus. While it is true that antiretrovirals help to ensure that people with HIV live longer and healthier lives, because the drugs reduce the amount of virus in the blood, it becomes much more difficult for someone who is adhering to treatment and whose viral load has plummeted, to transmit HIV to their partners through unprotected sex.
Antoinette Goosen, the National Chairperson of the South African Association for Campus Health Services, explained that HIV-positive students who were initiated onto ART are counseled extensively to ensure that they understand the importance of adherence to treatment and of safe sex to prevent HIV transmission. Goosen stated: ‘Half of the patients that we initiated onto ART last year were at death’s door. Within a period of two months, it was like waving a magic wand over these people’s bodies and lives. We saw such a dramatic change in them, that I can never ever think that the price and cost of ARVs can outweigh their benefits. These were young people who would have died last year. They are now at the point of completing their courses, graduating, and looking forward to the future.’
Julialynne Walker, Director of Development and Information for the Population Council, believes that, with ART provision comes the responsibility for treatment education and for programmes that address the other reproductive health needs of people living with HIV. Walker stated: ‘The health system has to begin to develop family planning for HIV-positive or sero-discordant couples.’
Despite common misconceptions about antiretrovirals, fuelled partly by the false claims of previous high-ranking political officials, South Africa’s antiretroviral treatment programme expands daily. At present, over 1.4 million people have initiated antiretrovirals, making the programme one of the biggest public health initiatives in history.
In the last decade, over seven million people living with HIV across the globe have begun taking antiretroviral treatment. The potential number of HIV transmissions that may have been prevented as a result of this is enormous, and will hopefully be quantified by future modeling studies.
The recent scientific breakthrough, in the form of the HPTN052 trial, shows conclusively that antiretroviral treatment also prevents HIV infections. These results have already begun to influence South Africa’s response to the HIV epidemic. Deputy President Kgalema Motlanthe announced recently that access to antiretroviral treatment would be provided to all South Africans with a CD4 count of 350 and below in the public health sector. While other government officials have alleged that this commitment to expanding antiretroviral access is unaffordable, sensitive costing studies have proven otherwise. One such study indicated that raising the CD4 count at which patients in South Africa initiated antiretroviral treatment to 350, in line with the recommendations of the World Health Organisation, would lead to a major net savings. [Hontelez JAC, de Vlas SJ, Tanser F, Bakker R, Barnighausen T, et al. (2011) This costing study concluded that, ‘Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon’. It recommended that South Africa should aim to expand its HIV treatment programme rapidly to provide treatment to all people living with HIV at a higher CD4 count of 350.
Professor Nicoli Nattrass, an economist and the director of the AIDS and Society Research Unit at the University of Cape Town, agrees that the long-term cost benefits of earlier antiretroviral initiation must be factored into government’s response: ‘It is crucial that government looks beyond the immediate budget cycle and considers health care costs over the longer term’, she stated. ‘It makes no sense to save money now by denying people early ARV treatment when this will actually save the government money over the longer term. Early treatment will reduce new HIV infections and prevent people becoming sick with AIDS. This will save the government huge amounts of money over the next three to ten years.’
The results of the HPTN 052 trial make it more urgent than ever for governments in South Africa and the region to scale-up antiretroviral treatment programmes. The moral imperative to provide treatment is now supported by clinical, epidemiological and fiscal evidence. For the first time in the history of HIV, science has shown that it is possible to end the HIV pandemic through timely, universal provision of treatment. By starting people onto antiretroviral treatment at an earlier stage in their disease progression with HIV, government has grasped a vital opportunity to prevent new HIV infections as well as reducing HIV-related illness and death.
Rebecca Hodes has a PhD in the History of Medicine from Oxford University. She is the Deputy-Director of the AIDS and Society Research Unit at the University of Cape Town.