The early treatment of people with HIV massively reduces their infectiousness and gives the world our 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.
‘This is the biggest news of the year,’ according to Dr Francois Venter, head of the Southern African HIV Clinicians’ Society.
‘No other intervention beyond abstinence shows such a level of protection. It’s probably even safer than condoms because things often go 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 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 means 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 put onto 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 actually stopped the trial early because the results were so ‘unequivocal’.
‘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 Venter.
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,’ said Venter.
Venter added that a CD4 count of 350, recently introduced 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,’ said Venter.
‘But there is very little health benefit for people with CD4 greater than 350 going on ARVs simply to protect their partners.’
The one drawback of the study is that only three percent of participants were men who have sex with 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.
‘I would recommend early ARV treatment in men who have sex with men, but without a solid research base,’ says Rebe, who runs the Ivan Toms Men’s Clinic in Cape Town.
‘We need the highest risk groups to be represented adequately in studies like this.’
Meanwhile, the health department’s Thobile Mbengashe described the treatment-as-prevention as a ‘game-changer’.
Speaking at a recent meeting, Mbengashe said that South Africa could carry on doing things as usual ‘ or we could hit the epidemic hard with a few proven interventions such as treatment-as-prevention that actually have a chance to halt the spread of HIV.
With the business-as-usual approach, ‘we will double the expenditure from R16 million to R32 billion by 2030. There will be an increase infections, death and costs and this is not sustainable,’ said Mbengashe.
But the approach being advocated by the new National Strategic Plan on HIV, due for release on World AIDS Day, advocates a rapid expansion of services aimed ensuring that 80 percent of people have access to annual HIV tests and the treatment of three million people with CD4 count of 350 by 2015.
‘We will probably end up spending the same amount of money as the business-as-usual approach, but we will have a far greater effect and we will have a chance to halt the spread of HIV, whereas the old approach is unsustainable,’ said Mbengashe.
The biggest obstacle to mass treatment, however, remains the fact that the majority of HIV positive South Africans still don’t know that they are living with the virus.
‘Although testing has increased significantly in sub-Saharan Africa in recent years, only about 20 percent of men and 28 percent of women in South Africa received an HIV test and result within the past year,’ according to Professor Salim Abdool Karim, head of the Centre for the AIDS Programme of Research in SA (CAPRISA).
‘The most recent national HIV survey revealed that 74 percent of those most at risk of acquiring the virus were unaware of their HIV status.’
A number of new approaches, including HIV self-testing kits, are being explored to ensure that all South Africans are able to know their HIV status, and if they test positive take advantage of treatment services and keep their sexual partners safe from HIV.