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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

The notion of treatment as prevention got a significant boost this week at CROI, where the results of a new study were presented by Deborah Donnell, MD, of the Fred Hutchinson Cancer Research Centre in Seattle. Dr. Donnell detailed exciting evidence that ART can prevent HIV acquisition, at least in the context of heterosexual, HIV discordant couples. 

In a multinational prospective study, researchers followed of a large cohort of couples in south and east Africa and looked at the role of ART in reducing transmission risks. The study tested the uninfected partner at the beginning of the study and at 3 month intervals, while providing free condoms and intensive prevention counseling to the couples. The infected partners were placed on ART when their CD4 counts dropped below 250.  Thirty-one percent of the infected female partners and 28 percent of the infected male partners reported unprotected sex.

The study was able to confirm whether HIV transmission occurred within the partnership through special testing.  There were 151 HIV transmission events, 108 of which were linked to partnerships.  Only one transmission event was found within a partnership where the infected person was on ART, while 102 HIV infections occurred within partnerships with no ART.  There was a 92 percent reduced risk of infection for the discordant partnerships where the partner was on ART. 

HIV transmission occurred at all CDR levels, but transmission rates were highest when the infected partners CD4 count was under 200.  This finding emphasizes the prevention imperative to expand ART access to the 40-some percent of persons in developing countries with CD4 counts below 200 who do not yet have access.

Interestingly, there was a significant reduction in unprotected sex in the partnerships where ART was introduced, from 6.2 percent to 3.7 percent.

Dr. Donnell noted that further research and more data is needed to evaluate whether prevention benefits would persist during long-term ART use. Click here to read a Reuters story on the study.

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

Attention turned to HIV among women and children at CROI today, when Elaine Abrams, MD, a senior a professor of pediatrics and epidemiology at the Columbia University College of Physicians & Surgeons and the Mailman School of Public Health, provided an informative  overview of the challenges in protecting children from HIV in developing-world settings.  For starters, she said, we are not doing a very good job in preventing HIV infection in women, with 1 million new infections a year in women. Then there are the 1,000 new pediatric HIV infections every single day. And in most high prevalent developing world settings, there is very poor access to family planning services, leaving women with few tools to prevent unwanted pregnancies.

In the context of antiretroviral therapy scale-up, there has been a failure to identify and prioritize pregnant women for ART who are at risk of transmitting HIV infection to their infants.

There has also been limited scale-up of prevention of mother to child transmission programs, in large part because these programs are layered into the limited infrastructure available in many countries for maternal and child health services. Too often, there has been an over-reliance on short-term ART for pregnant women, rather than a continuum of care and treatment for HIV-infected women and their children.

Until recently, there was no ART intervention for prevention of post-natal transmission, leaving many infants vulnerable to HIV transmission during the breastfeeding period. Current strategies using daily neviripine in infants during breastfeeding reduces the risk of HIV acquisition, but it also confers neviripine resistance on infants who fail prophylaxis at very high levels – some 52 percent.  Drug alternatives to neviripine are not widely available.  The public health approach to ART access in developing-world settings is anchored in neviripine-based regimens.  Lopinivir is the only protease inhibitor available for infants.  In general, there are very few ART options available for children in resource-poor countries, especially in the context of widespread neviripine resistance.

Dr. Abrams also noted that there is very limited capacity for early diagnosis in infants, even though mortality in this population is extremely high.  Thirty-five percent of HIV-infected infants, if untreated, will die in their first year of life, and that number increases to 53 percent by age two.  The World Health Organization recommends that all HIV-positive children under age 1 should receive ART therapy.

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

The evidence for scale-up of home-based testing is straightforward and compelling. In Africa, an estimated 17 million people with undiagnosed HIV infection are responsible for 90 percent of infections. Testing rates remain low in many sub-Saharan African countries, but home-based testing has proven to overcome many obstacles that keep people from finding out their HIV status in clinics.

Peter Cherutich, with the national AIDS program in Kenya, detailed the promise of home-based testing in a talk at this week’s CROI meeting in San Francisco entitled “HIV Prevention and Care through Door-to-Door HIV Testing and Counseling:  Opportunities and Challenges.”

He began by reminding us all that testing is the foundation of HIV prevention and that knowledge of serostatus is effective in reducing risk behavior.  A survey in Kenya found that HIV-infected persons who knew their status were 15 times less likely to engage in unsafe sex than those who do not.

And reticence to getting tested remains high. For example, a review of testing rates across a number of sub-Saharan African countries found the highest rates in South Africa, where 28.7 percent of women and almost 20 percent of men reported testing in the last year.  This is in part because the model of voluntary counseling and testing is client-driven, requiring clients to self-identify as at risk. There are also challenges with health care facility-based testing, including the burden of transportation.

 Home-based testing and counseling overcomes the obstacles of cost and transportation.  It also encourages discussion within families and ensures that consent and confidentiality are protected.

There are basically two types of home-based testing and counseling (HBTC): door-to-door testing of the general population and targeted testing of household members of HIV-infected persons in care and treatment.  Home-based testing is most effective and a wise use of resources in countries with high HIV prevalence, generalized epidemics, high density urban or rural areas, and sizeable populations on ART.  Uganda, Kenya, Malawi, Zambia, Swaziland, and Lesotho all have robust HBTC programs.  Uganda and Zambia have data showing that people are much more likely to be tested in a home context.  (more…)

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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

The opening day of CROI included a session on the future of PEPFAR, featuring the US lead on global AIDS, Ambassador Eric Goosby, MD, as well as the health minister of Namibia and the UNAIDS deputy director.  Kevin De Cock, MD, recently named the head of global health at the CDC, moderated the session.

Goosby opened his talk by assuring this HIV scientific audience that the Obama Administration is focused on “maintaining, extending and increasing” the US response to global AIDS and described the President’s FY 11  $7 billion for PEPFAR, the largest request to date.  (Presumably, this $7 billion figure includes bilateral global TB activities as well as the Administration’s request for the Global Fund—which actually reflects a net  reduction from the amount that was appropriated for the current fiscal year.) Goosby talked about using key lessons learned to build the future of PEPFAR. He catalogued those lessons as follows:

*The HIV response has benefited both health systems and health status with, for example, reductions in hospitalization, coinfection, and  stigma

*Goals and targets help to drive programs and need to be modified as programs mature

*Prevention programs require targeted, data-driven responses

*Emergency response mechanisms must be supplanted with efforts to build country capacity to develop and coordinate a response to the epidemic

*The US must be able to demonstrate the impact of every dollar we spend.

Goosby then highlighted some of the major components of the new 5-year PEPFAR strategy, released in December:

  • Promotion of sustainable country programs
  • Strengthening partner government capacity
  • Expansion of prevention, care, and treatment in both concentrated and generalized epidemics
  • Integration and coordination of  HIV programs with broader global health and development programs
  • Investments in innovation and operations research.

Ambassador Goosby told the audience that his office was actively engaged in dialogue with the Global Fund , other bilateral programs, and foundations about ways to effectively converge resources and to identify efficiencies and savings.   As he has frequently done in other public statements, he spoke about the need for country ownership, but he explicitly described this as ownership by country and civil society.  This inclusion of civil society will no doubt be reassuring to some, but so far, civil society participation in the development of the 5-year partnership frameworks that the Office of the Global AIDS Coordinator is working on with a number of countries has been extremely variable and quite limited in some contexts.  He also pointed out that in most cases, in the near term, country ownership was more about control in identifying priorities and administering programs than actually providing the financing.  In particular, he highlighted transitioning to local partners as the dominant source for service delivery.

He noted that he thought that PEPFAR could make an important contribution to the global evidence base around effective prevention and described prevention as a combination of biomedical interventions, behavioral interventions, and structural/policy and social changes.

In regard to HIV treatment, Goosby said that expanding treatment and ensuring quality would continue to be a priority as the program moved from providing treatment access to 2.4 million to the “mid 4 millions.”  PEPFAR would also continue to provide technical support around treatment guidelines, ensuring retention adherence, and monitoring drug resistance.   PEPFAR is also committed to maximizing the use of pooled procurement for drugs and laboratory commodities and the use of generic ARVs , which is currently 89 percent. (more…)

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This post is by Global Center Director Christine Lubinski, who is attending the Conference on Opportunistic Infections and Retroviruses (CROI) this week in San Francisco. This is her first post; check back regularly for her blogs throughout the conference.

The opening plenary of this leading HIV scientific conference—titled “Guiding the Global Response”—highlighted efforts to model the impact of ART as a prevention  and treatment tool to ultimately end the epidemic. CROI’s kick-off session also showcased issues related to couples and offered an assessment of current treatment strategies and scale-up in Africa.

In a talk entitled, “Put Your Money Where Your Model Is:  ART for Prevention and Treatment of HIV,” Brian  Williams, a modeler from South Africa asked why, despite the expenditure of $150 billion, the world has failed to control HIV transmission. He theorized that if an average of 7 people are infected by any one person, and if we reduce transmission 7 fold, we can eliminate HIV.  ART reduces viral load by 10,000 times, so if we start ART within one year of seroconversion and reduce Infectiousness by 70 percent, we can end the epidemic, Williams said.

While physicians and scientists are beginning to identify people early enough to save them from death, they are not intervening early enough to keep people from transmitting HIV to others.  He proposes a “test annually and treat immediately” strategy for low-prevalence settings, and a combination of test and treat and pre-exposure prophylaxis—or PREP—in high prevalence settings, like South Africa, which has a 17 percent HIV prevalence. Williams suggests that PREP would be appropriate for younger persons at high risk, while a test and treat strategy could be effectively deployed for older persons.  Benefits of this type of early intervention include a reduction in TB of about 60 percent.  Moreover, he noted that HIV-positive persons have a 2.5 times greater risk of mortality, compared to their HIV-negative counterparts, regardless of CD4 count or level of immunosupression.

Williams acknowledges that these strategies will require  a big initial capital outlay, but notes that we will ultimately save money in the long run.  If we don’t take measures to stem HIV transmission, we will continue to need huge fiscal resources to respond to the epidemic.  According to Williams, we can expect to spend $60 billion dollars, and the question is whether we will save millions of additional lives while incurring those costs.

He highlighted recent successful efforts at community-based testing in Kenya as an indication that test and treat could work. But an audience member responded that only about 30 percent of those identified as positive in this campaign were successfully linked to care and treatment.

Dr. Rebecca Bunnell, from the CDC, outlined the centrality of couples in the HIV epidemic in Africa and attributed the failure to significantly reduce HIV transmission rates in part to a failure to employ couple-based strategies.

She noted that the term “couple” describes many types of partnerships and that there are cultural, legal, and regional variations.  In a number of African countries in east and southern Africa, the majority of HIV-infected persons cohabiting are married.  Mutual knowledge of serostatus is low, and condom use is low. In east Africa, 40 to 50 percent of married HIV-infected persons have an uninfected spouse. There are an estimated 340,000 discordant couples in Kenya.  In Uganda, 74 percent of recent infections occurred in married couples. Studies have also shown that MSM who are part of a couple have a higher HIV risk than those who are not paired, as a result of more sex acts, more receptive sex, and less condom use. (more…)

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One of the most important scientific HIV/AIDS conferences will open next week in San Francisco—the 17th Conference on Retroviruses and Opportunistic Infections. You can get news from this invitation-only event here at Science Speaks, as well as at www.aidsmap.com, which will be providing in-depth coverage of the conference. Science Speaks will have updates on the new HIV/AIDS science  presented at CROI, as well as associated policy implications of new approaches to HIV treatment, prevention and care.

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