The big picture: the evidence is in that it works
“It’s time” was the unofficial theme, or perhaps subtext, of the International Treatment as Prevention Workshop held last week in Vancouver, a gathering of policy and decision makers, researchers and community from around the world. Altogether 250 delegates came from 41 countries to review progress and plan next steps. PositiveLite.com was there.
Next steps do not necessarily call for gathering yet further evidence to prove that treatment as prevention works. “There is no need for further discussions. The main discussion is how to implement treatment as prevention” said Dr Luiz Loures, Deputy Executive Director, UNAIDS in an opening address. And that is indeed where the ensuing three days focussed, as delegates from countries around the world reported in on their results, their challenges and how they intended to end the epidemic back home.
Dr. Julio Montaner, conference chair and director of the B.C. Centre for Excellence in HIV/AIDS and internationally recognized as one of the world’s leading TasP proponents (left, photo by Bob Leahy), said it best. “We are at a critical time where finally there is a voice of consensus emerging—that treatment is highly effective at stopping HIV transmission.” While it may be unrealistic to suggest that consensus is universal - the conference was as notable for who was NOT there as for who attended (more on that later) – Montaner noted that the evidence has firmed up appreciably even in the last year. He cited the recent release of the interim PARTNER study results at CROI 2014 where there were no new infections in a large cohort of people with undetectable viral load, heterosexual or homosexual, confirming in effect the results of HPTN 052 and the often dismissed Swiss Cohort Study before that. While not feeling they went far enough, Montaner is nevertheless buoyed by last year’s revision of WHO recommendations on when to start treatment. The suggestion now stands at a CD4 count of 500 but we seem to be trending upwards towards a recommendation of treatment on diagnosis, a key element, along with ramped up testing initiatives and retaining people in care, of most treatment as prevention strategies.
Who is on side? In Canada, it's only the province of British Columbia with it’s abundantly clear, the full support of the province’s Minister of Health, who was in attendance. Elsewhere in Canada it’s patchy. San Francisco is fully on side and like B.C. is showing a marked reduction in new infections. New York City and Washington D.C. have also bought in. Globally, China, France, Vietnam and Brazil are major TasP players with a dozen or so African nations with TasP initiatives well under way.
Where does the opposition to treatment as prevention come from? “Doctors and the community” cited one expert. The concerns, as outlined by Gus Cairns of NAM/Aidsmap in a Day 4 presentation, reflect that there has always been tension around TasP. "‘Motives for taking or not taking meds are as idiosyncratic as people are” he said. Cairns suggested that these motives often have a historical background. “There is a perception that HIV drugs are “toxic”” he said.” And “there is resistance to the idea, even after CROI 2014, that ART really does reduce the possibility of infection to that indicated by the latest research.” (See here for more on this topic on PositiveLite.com.)
(Not all community activists, of course, oppose treatment as prevention. One community member from Greece, on the opening plenary panel, in fact, suggested we have to start castigating those countries who are not controlling new infections by means of TasP. And those other community members present at the conference - there was a smattering from B.C. but no one from Eastern Canada - all seemed fully supportive of TasP, as has PositiveLite,com been for quite some time.)
The difficulty in bringing incidence down in the gay (MSM) population, often used by opponents to suggest that TasP doesn’t always work inevitably came under the spotlight. The take home message? Clearly populations where the prevalence is already very high like that occurring in MSM in large cities present challenges, but appear surmountable, according to Montaner. In gay men it’s not about the biology of anal sex as has been suggested in the past, he says. The key is to ramp up testing to bring into the treatment fold the undiagnosed plus vastly increase the number of those men with an undetectable viral load, possibly to the 90% level according to British modellers. However, treatment on diagnosis is a sticking point for some community activists who cite factors such as the possibility of long term side effects emerging, indicating, they say, the need for caution in advocating for early treatment.
On the effectiveness of TasP in MSM, Montaner said of the PARTNER study "it gives us a great deal of confidence that if we continue to ramp up TasP in the homosexual community we will see an impact". Describing doubters as ”slaves to the evidence who require 100% proof”, he added “practical minds say we just have to move on.”
Montaner questioned the priorities of the Federal Government in Canada. “We have written to the Federal Government every year since 1996 (about implementing TasP across Canada) and the answer we have got every year is “no thank you.”” The key to BC’s success he feels, which he would like to see duplicated across Canada but is clearly frustrated that it isn’t, is providing truly free services and HIV meds, developing a focus on infected populations and bringing the services to the people. In B.C. this has translated to “test and treat” while researching the impact of more universal testing standards. So B.C. has moved towards an HIV test in the general population whenever blood draws are ordered by general practitioners and in all intersections with hospital care, with a recommendation that all HIV-positive individuals be offered no cost treatment on diagnosis, irrespective of CD4 count, a measure also adopted by 26 other countries.
Other emerging themes
. The concept of the HIV treatment cascade has emerged as a key reality in visualizing and ultimately measuring the efficacy – a “surrogate measure” - of treatment as prevention.
. Undiagnosed HIV, the source of the majority of new infections now, is seen as a key nut to crack.
. While capturing acute infections in the undiagnosed by ramped up testing and offering immediate treatment are key elements, the importance of retaining people in care and facilitating adherence to meds - there is slippage in almost every jurisdiction featured - is equally important in bringing individual and population viral load levels down.
. We need the tools to help people along the treatment cascade.
. There is an increasing focus on implementation science as opposed to debate as to whether or not TasP works.
. The debate as to whether universal testing is cost effective seems to be won by those jurisdictions who are finding significant enough levels of infection in undiagnosed patients, many of whom were not considered as being from at-risk populations. (In some cases. such testing has resulted in seven new diagnoses per 1,000 tests.)
. Globally there are significant pharmaceutical supply chain challenges, not to mention economic mountains to climb, in bringing the number of those on treatment from their current levels of approximately 19 million (or 68% coverage worldwide.) Representatives of the pharmaceutical industry, including generic and name brand manufacturers, seemed to indicate the demand could eventually be met, although the issue of political will to extend coverage on this scale needs to be demonstrated.
. Aside from B.C. the rest of Canada is falling behind many countries with a more progressive approach to HIV prevention and patient care.
. PrEP received little coverage at the conference, perhaps in part reflecting Montaner’s view, expressed in 2103 and reinforced in 2014, that PreP is “a distraction” from the main event.
. Treatment as prevention is not a simple science and there is no magic bullet to end the epidemic. In particular there remains a need for other strategies outside the realm of the biomedical including behavioural and condom-based interventions. (Interestingly there was little discussion on the impact of social determinants of health, a mainstay of older generation prevention strategies in many jurisdictions.)
. The need for community consensus. In this connection, Gus Cairns presented a statement of overarching principles that was launched earlier this year by NAM/aidsmap and the European AIDS Treatment Group (EATG), which currently bears over 300 signatures, including that of PositiveLite.com. (The consensus statement is accessible at www.hivt4p.org. Please consider signing it.)
In a world where funding is limited, how do you determine how to spend prevention dollars? That was the theme of an interesting session featuring three distinct approaches – the biomedical, the behavioural and the focussed.
The conference daily bulletin reported thus. "Dr. Over, from the Center for Global Development, argued for a behavioral-first approach. Individual behavior, he said, is the most important determinant of HIV infection and treatment success. The biomedical approach was argued for by Dr. Lange, who advocated for treatment as early as possible. Early treatment, he said, maximizes both individual and public health benefits.
Dr. Williams, from the South African Centre for Epidemiological Modelling and Analysis (SACEMA), advocated for hotspotting — targeting those regions where the HIV epidemic is most concentrated. Efficiency, he said, dictates that we should test where the prevalence is highest." (More on this approach in this aidsmap article.).
Given the avalanche of research which suggests that biomedical solutions are effective at both the individual level and, with more challenge, at the population level also, it was hard not to agree that Dr Lange won this debate hands down, at least as to core strategy, with Dr. Williams making a good case for where best efforts be directed.
(An interesting feature of the data that Williams presented was in its detail and sophistication in a South-African based model. In fact surveillance as to where people stand on the various steps of the treatment cascade is very complete in parts of Africa, as well as in countries like Vietnam and China, right down to the village level. That same ability does not exist in Canada. Should one want to know how many people in Canada have an undetectable viral load, for instance – a key indicator in monitoring treatment as prevention efficacy – there exist only estimates. In fact a widening gap between the advanced capabilities of what were once thought of as “third world countries” and Canada – both in effective responses to the epidemic and in the infrastructure supporting them – was one of the key messages this observer brought home.
While the conference was several times characterized as “preaching to the choir” and that instead it needed to better embrace the wider community, there is little doubt that these meetings of largely like minds are exceedingly important. In fact the conference comes at a time when the evidence is stronger than ever and that more and more are siding with the growing list of supporters of treatment as prevention in North America and around the world.
It is a time, many consider, of shifting views.
But there are challenges to overcome. “Ideology is alive and well in this country” said one speaker of Canada. And there is a body of people and institutions who require exceedingly high standards of proof in order to depart from previously held positions embedded in the history of the AIDS movement.
Having said that, we as a community advocate for a science-based approach to HIV prevention, and this conference was not short on presenting overwhelming evidence not only on the efficacy of using ART to reduce HIV incidence and improve individual and population health outcomes, but in doing that well.
The presence at the conference of organizations like UNAIDS and the World Health Organization in supportive roles cannot be ignored, but nor can the absence of huge segments of the prevention community here and elsewhere.
Clearly the conference was effective in advancing a treatment as prevention agenda but in doing so also exposed the huge amount of work that needs to be done, with advocacy at all levels being a sizeable component.
What was said (quotable quotes)
“We should be setting one goal, and one goal only: to end HIV as an epidemic. We will defeat this epidemic” Dr. Mark Dybul, Executive Director of the Global Fund to Fight AIDS, Tuberculosis & Malaria.
“Can we afford not to treat?” Hon. Clarice Modeste-Curwen, Minister of Health, Grenada
“Politicians need to follow the evidence, not the ideology” Hon Terry Clark, Minister of Health, British Columbia
“Just watch me”. Dr Julio Montaner, when asked if it is possible that undetectable viral load goals of 90% of the infected MSM population in B.C. are possible to attain.
And . . . “the time is always right to do what is right” Martin Luther King.