OPINION. One objection against the use of ARV treatment for HIV prevention is that it puts people on treatment whilst they may clinically not need it. My first reaction to that is to ask when is it clinically relevant to treat an HIV infected person? So far the various guidelines produced are clear and based on the CD4 count. But the guidelines have changed during the years and the goalpost has been moved from below 200 to below 350 and soon to below 500 and is reaching the mean Cd4 count in healthy population. My second reaction is to ask, what about the other benefits, not clinical, of being on treatment?

In a retrospective analysis of pregnancies conducted to determine the optimum time to start HIV therapy during pregnancy presented at BHIVA, Read et al. observed a strong correlation between the time at which ART was started and achieving an undetectable viral load by the time of the delivery. Mothers with high viral load should not delay ART in order to achieve undetectable viral load and therefore reduce the risk of transmission to the child at birth (Read PJ. Achieving an undetectable viral load in pregnancy: are we starting HAART early enough? HIV Medicine 11, supplement 1, abstract O1, 2010.)

“The results of the study indicate that while women with VL <10,000 copies/mL can defer HAART to 26 weeks, those with VL >100,000 copies/mL should start treatment without delay if they wish to achieve undetectable VL at delivery — a prerequisite for a vaginal as opposed to a C-section birth. For intermediate cases, commencement at 20 weeks or earlier may still be advisable” wrote Evelyn Harvey for Doctor’s Guide.

Maternal Mortality Ratio per 100,000 livebirths, 2008 (Source: The Lancet)

Previously, the Lancet published a systematic analysis of maternal mortality for 181 countries between 1980 and 2008. The researcher observed a “substantial, albeit varied” progress towards MDG 5 (Improving maternal health). But they also noted that “In the absence of HIV, progress in sub-Saharan Africa in reducing the MMR would have been much more extensive than we recorded.” Hinting that putting mothers on treatment would have reduced MMR further.

Discussing the lack of progress on maternal mortality in southern and eastern Africa, Dr Christopher Murray of the Institute of Health Metrics and Evaluation at the University of Washington told The New York Times:

“It means, to us, that if you want to tackle maternal mortality in those regions, you need to pay attention to the management of HIV in pregnant women. It’s not about emergency obstetrical care, but about access to antiretrovirals.”

Crucially, AIDMAPS quoted Robin Gorna, executive director of the International AIDS Society saying “HIV services do not compete with other health priorities. They support them by reducing all-cause mortality; improving maternal health; improving child health by preventing and treating HIV disease in children and reducing diarrhoeal and other diseases through safe breastfeeding. This study reminds us that those who seek to pit maternal health against HIV in a competition for resources are deeply misguided.”

A study conducted in Kenya by R. Scott McClelland et al. observed that contraceptive use increased by over 50% after starting antiretroviral therapy in a cohort of HIV-positive female sex workers in Mombasa (comment at AIDSMAP).

Earlier this year, AIDSMAP reported on the results of the partner in prevention study that “HIV transmission between long-term, HIV-serodiscordant heterosexual couples in Africa has found that the chance of transmission is reduced by at least 90% if the HIV-positive partner is on antiretroviral therapy.” These two studies show a positive impact on behaviour, in particular condom use.

There are growing evidences that being under treatment reduces viral load and hence infectiousness in all these studies (see further reports from CROI 2010) . But as the evidence is mounting in favour of starting treatment earlier without consideration for shifting and difficult to assess individual clinical needs, how long will it take to convince opponents to the test and treat approach that starting treatment ASAP has a crucial role to play in prevention?

How many life could be saved by gearing up voluntary testing, counselling AND early/immediate treatment? How many won’t be saved by procrastinating attitude pitting individual health and public health one against another when clearly they both benefit from each other?

The new motto for HIV prevention is “evidence-based interventions”; the evidences are out there.

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