People with HIV who are on antiretroviral medicine and have an undetectable level of the virus are at virtually no risk of infecting their partners.
This ground-breaking new research makes it possible for South Africa to cut HIV transmission substantially by using ARV treatment.
North Carolina University’s Dr Myron Cohen received a standing ovation when he reported on the research in Rome earlier this year, and AIDS experts have called it “the biggest news of the year”.
Cohen’s research involved 1 763 couples, where one was HIV positive and the other HIV negative. Nine countries, including South Africa, were involved and couples in Soweto and Cape Town took part.
All the HIV positive partners had CD4 counts of between 350 and 500, which means that they did not yet need ARVs.
The couples were randomly divided into two groups. In the first group, the HIV positive partners were put onto ARVs immediately. In the second group, ARVs were delayed until the partners with HIV reached a CD4 count of 250 or they developed an AIDS-related illness.
The difference between the two groups was striking. In Group One, only one person became HIV-infected but in Group Two, 27 people got HIV from their partners. This meant there was a 96% reduction in transmission in the early treatment group. “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,” says Dr Francois Venter, who was on the data and safety monitoring board of the Cohen trial.
It 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 an undetectable viral load.
“I would say that people who are on successful ARV treatment are 100 percent safe and will not transmit the virus,” says Venter.
Venter added that a CD4 count of 350, recently introduced as the standard for treatment in South Africa, was also the optimal time to start ARVs.
“If all HIV positive people started ARVs at CD4 350, this would have a massive effect on transmission. But there is very little health benefit for people with CD4 greater than 350 going on ARVs simply to protect their partners,” according to Venter.
The implications for South Africa, where almost one in five adults (18%) are living with HIV, are massive. There could be a very substantial reduction in HIV transmission by testing and treating those who needed it.
The New Strategic Plan for HIV/AIDS, which was released on Thursday (1 Dec), stresses the importance of every South African being offered an annual HIV test.
A huge obstacle to our HIV policy is that most people don’t realise that they have HIV until they’re sick. Yet scientists say that the optimal time for HIV positive people to go onto ARVs is when their CD4 count is 350 – in other words, before their immune systems are too damaged to rebuild.
Down in the Western Cape, Premier Helen Zille is trying to entice people to take an HIV test by offering R100 000 in prizes in a lucky draw for testers.
Although she has been widely condemned for this, frankly South Africa should embrace any non-coercive method of getting people to test.
Unfortunately, Zille’s testing scheme seems motivated to by the desire to identify and punish those who are positive and infect others with HIV.
“There is absolutely nothing wrong with society requiring people to know their status, and acting appropriately on the basis of that knowledge - or face the appropriate criminal sanctions,” says Zille.
But when governments try to police people’s sex lives, all that usually happens is that the sexual practices they don’t like get driven underground.
Why should a person who suspects they have HIV take a test in the Western Cape if they know this result in them being charged for culpable homicide or even murder?
Instead of waving the big stick, Zille should reward HIV positive people who maintain an undetectable viral load, as they then have a tiny chance of infecting anyone.
The challenges of implementing the treatment-as-prevention policy are test, treat and keep on treatment.
Lynne Wilkinson is head of Medicins sans Frontieres’ in Khayelitsha, which has the longest-running ARV programme in the country. She warns that the only way to keep people on ARVs over a long period, is to make it easy for them to get and take their pills.
“The only way we are going to succeed with starting all people who need antiretroviral therapy in South Africa, three million by 2015, is to decongest our health facilities so that they have the capacity to manage newly diagnosed patients and patients who require additional care,” says Wilkinson.
“Can we really expect a person who has been on ARV treatment for years, to take a full day off work once a month, pay exhorbitant taxi fare and sit in a clinic for most of the day, to get one month’s ARV drug supply? Are we really surprised when a person eventually weighs up the risks and benefits in favour of defaulting their treatment?
MSF has started “adherence clubs” aimed at getting people on ARVs to support one another but, more importantly, for these clubs to distribute ARVs to their members instead of them having to go to the clinic every month.
Another way of making treatment easier is the “fixed-dose combination” drugs, which in ordinary people’s language means combining three different ARVs into one pill.“Fixed dose combinations are great and we should advocate for lower prices and use them when possible,” says HIV Clinician Dr Tom Boyles. “They may help with adherence but they also can considerably reduce the time taken to dispense medicines which can be a limiting factor in some clinics particularly in rural areas where there is a chronic shortage of pharmacy staff and valuable nurse time can be used up in dispensing medicine.”