Fwd: [RectalMicro IRMA] Lancet editorial - Treatment as prevention for HIV

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Treatment as prevention for HIV
June 5, 2011, was the 30th anniversary of the first reports of five patients with an immune disorder in the US Centers for Diseases Control and Prevention publication Morbidity and Mortality Weekly Report. In the past three decades, HIV/AIDS has become a global pandemic that has defined an age and has affected almost every group of people irrespective of socioeconomic background, race, geography, or personal history, killing more than 33 million people worldwide. Leaps and bounds made in our understanding of HIV and its progression to AIDS and how the virus and syndrome spread and develop have led to great progress in the ability to manage the disease, reflected by a 20% fall in annual incidence in the past 10 years. Nonetheless, almost 2 million people continue to die each year from AIDS, disproportionately affecting sub-Saharan Africa. Furthermore, incidence continues to rise in specific risk groups such as men who have sex with men, injecting drug users, and female sex workers.
The Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention held in Rome in mid-July, provided the global AIDS research community with an opportunity to reflect on the past 30 years and to look forward to the next stages in the fight against HIV/AIDS. A broad diversity of topics from basic research to programme implementation was covered, but the conference was dominated by one message that was repeated time and again in the press conferences, scientific sessions, and the rapporteur summaries: "treatment is prevention". The phrase became something of a mantra.
In the past year, the results of several major trials have shown that in addition to behavioural interventions pharmaceutical products can help to reduce transmission rates of HIV. In July 2010, the CAPRISA 004 trial showed that a vaginal gel containing tenofovir could help to prevent HIV acquisition. Also in 2010, results of the iPrEx trial showed that a daily antiretroviral pill could help prevent acquisition of HIV among transgender women and men who have sex with men. Treatment as prevention took a blow in 2011 when the FemPrEP trial failed to show an reduction in HIV acquisition with the use of tenofovir tablets by heterosexual women, but as reported in this month's Newsdesk, in the weeks preceding the conference in Rome hopes were again bolstered by the results of several trials showing positive effects of antiretroviral prophylaxis for both men and women in serodiscordant couples and in high-risk populations.
The findings of these studies are certainly encouraging and the addition of antiretroviral drugs to the armamentarium of approaches to prevent the transmission of HIV is to be welcomed. The past 30 years have shown that reductions in HIV transmission and the burden of AIDS rely on a combination of approaches that need to be tailored, adapted, and selected on the basis of the specific situations and populations. Already, successful treatment to control viral load is helping to prevent transmission, and the role of antiretrovirals will grow as the results of the new trials inform future programmes.
Enthusiasm generated by these results must be tempered with caution. A shortfall exists in access to antiretroviral drugs for populations in need of treatment to prolong their lives. In the face of the current global economic situation, how can these drugs be provided as prevention to those high-risk populations, while people with the disease in need of treatment continue to go without?
Expanding the use of antiretrovirals to include pre-exposure prophylaxis will increase the risk of resistance, which is already a serious problem. HIV is a rapidly evolving virus and development of resistance creates the need for ever changing regimens of drugs in various classes. The current dire situation with antibiotics should serve as a lesson to initiatives seeking to increase the ways in which we use antiretroviral drugs.
Furthermore, although some of the trial results have been very impressive, the protection with pre-exposure prophylaxis is unlikely to be 100%, and making drugs available as prophylaxis could encourage high-risk sexual behaviour among those who believe themselves to be protected.

Integration of antiretroviral prophylaxis into HIV prevention strategies must not be at the expense of tried and tested behavioural interventions, and care must be taken to safeguard the usefulness of these drugs for treatment in the future and to encourage a healthy drug-development pipeline. The fight against HIV/AIDS is a long-game, and current enthusiasm for positive results must lead to approaches that are sustainable in the long-term.

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