HIV remains an elusive enemy. A variety of major impediments stand in the way of broad impact scale, such as identifying infected and uninfected at high risk. There are an estimated 34 Million infected people globally of which some 6.6 million are already taking ARVs. But 2.7 Million become infected each year. Identifying and reaching a major proportion of the infected but untreated and frequently un- aware people is a mammoth task. Countries are still faced with challenges in that many people are difficult to reach out and or resistant to testing. The perpetual stream of newly infected people increases the testing burden and again there is also the challenge of acceptance and long term adherence. For ARVs as prevention to have a substantial impact, very large numbers of those persons testing positive, most symptom free would need to take them voluntary and consistently for a life time. Evidence from some African countries indicates the proportion of ARV recipients with resistance has increased each year since ARV roll out.
ARVs however, definitely have a supporting role to play in prevention as part of combination approach to treatment. In 2011, UNAIDS unveiled a new long term vision for the Global AIDS response. Zero new infections. Zero discrimination. Zero AIDS related deaths. The articulation of such an inspirational statement ought to raise a number of questions by various players, researchers, commentators and public policy makers. HIV/AIDS researchers have long debated whether antiretroviral (ARVs) used to treat HIV- infected people might have a double benefit and cut transmission rates. A consensus statement issued by the Swiss Federal Commission for HIV/AIDS in 2008 that said effective ARV treatment could virtually stop heterosexual transmission was denounced as appalling, inconclusive and irresponsible and dangerous and misleading. As a result of this, UNAIDS and WHO responded with alarm urging people to continue using condoms and stressing that vaginal secretions might harbor the virus even when blood tests showed no trace of it. They cautioned that more research needed to be carried out in order to determine the degree to which the viral load in blood predicts the risk of HIV transmission.
AIDS responses have created a huge body of knowledge about HIV transmission and how to prevent it. A number of studies on using treatment as prevention are ongoing globally compelling researchers and observers to ask whether ARVs are a ‘Magic Bullet’ that can stop the global epidemic in its tracks. One such study that has been undertaken is the “Initiation of Antiretroviral Treatment protecting uninfected sexual partners from HIV Infection (HPTN 052). HPTN 052 is the randomized clinical trial to show that treating an HIV infected individual with ART can reduce the risk of transmission of HIV to an un infected partner. The trial is conducted by the HIV prevention Trial Network (HPTN). HPTN 052 began in April 2005. The study was conducted in 13 sites and this included Botswana and in Botswana 77 couples were enrolled. The HIV infected person was required to have a CD4 cell count between 350 -550 at enrollment and therefore, did not require HIV treatment for his or her own health. Couples were randomized to one of two groups. In one group, the HIV infected person immediately began taking ART. In the other group, the HIV infected person began ART when their own CD4 cell count fell below 250 or if they developed an AIDS related illness.
The several studies that have been undertaken including in Botswana in order to reduce the viral load and thereby reduce individual infectiousness are indeed sobering. They present themselves as game changers and that indeed with full commitment zero infectious rates can be attained. As a result of the studies undertaken, many countries are now showing low incidences of HIV/AIDS. It is quite evident that there are still many challenges lying ahead and in the studies themselves, ARVs however, present its potential to contribute to the existing combination arsenal such as circumcision, condoms, behavior change and others.
The HIV Prevention Trials network reported that ARVs reduced the risk of heterosexual transmission by 96%, the HPTN 052 study. The HPTN 052 randomized study confirmed earlier observational data that, if the HIV positive partner in a discordant couple took ARVs transmission to the HIV negative partner was virtually eliminated, at least for more than two years. Other randomized studies found that taking ARVs by the HIV negative partner in a discordant couple pre exposure prophylaxis (Pr EP) also reduced transmission substantially. These results have ignited enthusiasm for ARVs as a breakthrough for HIV prevention, something that the UNAIDS Executive Director Michel Sidebe described as ‘Game Changing. The HPTN 052 results and other recent success trials such as the Pre-Exposure Prophylaxis (IP Pr EX) have showed positive developments. Unlike the many HIV prevention trials that have failed or had positive but barely significant results (IP Pr EX) showed unequivocally that the treated groups had 44% fewer infections after an average of 1 ÔÇô 2 years. The IPrEX study has a clear cut message, ‘that a pill can dramatically lower the chances of HIV through receptive anal intercourse in Men who many sexual partners. It is therefore, highly recommended that the drug should be offered as part of a prevention package that includes condom promotion and counseling.
There has been other studies undertaken such as the “Vaginal and Oral Interventions to control the Epidemic” (VOICE). VOICE is an HIV Prevention trial that evaluated two antiretroviral (ARV) based approach for preventing the sexual transmission of HIV in women had to be discontinued. It was found that the vaginal gel which contains the ARV Tenofovir was found not effective in preventing HIV in the women enrolled in the study. Tenofovir gel is a vaginal microbicide that contain the same active ingredient as the oral tablet. Microbicide are products designed to prevent or reduce the sexual transmission of HIV when applied topically on the inside of the vagina or rectum, (http:www.mtnstopshiv.org). These studies were conducted in Uganda, Zimbabwe and South Africa did not yield significant positive results.
Whilst ARVs are not a magic bullet, enhanced political commitment and accountability in ensuring for their availability is a step in the right direction, Health is a public good and everyone must have the right to treatment access irrespective of the ability to pay. In Botswana, placing HIV at the highest level of development and security and establishing a clear focus on results and accountability has been a priority during former President Mogae’s era. The current regime has acknowledged that it is experiencing financial shocks that call for belt tightening in resource allocation and that provision of ARVs are not sustainable.
ARVs are necessary and provision of them to citizens at no cost needs to be continued. There is also a need for the government to develop new innovative ways of ensuring for health care financing to ensure for sustainability and continuity of providing free ART to the citizens. The recent case which the government of Botswana has been ordered to provide ARV treatment to HIV positive foreign prisoners at state expense is a welcome development. The judgment passed means that government of Botswana is legally obligated to immediately provide life saving ARV treatment to foreign prisoners living with HIV. ARVs have created hope and if applied with the new WHO specified threshold of 350 ÔÇô 500 CD4 count then indeed there is hope that can mark ‘THE END’ of the pandemic.
Thabo Lucas Seleke is a Researcher and Scholar in Global Health Policy and Health Systems Strengthening.
