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ART Treatment as Prevention to Decrease HIV Transmission

Jan 23, 2012 Letters

Dear Editor,
Throughout the history of public health, whenever there was no cure for a disease, prevention measures became the top-tier strategy for reducing its spread.
Today, globally, the perpetual absence of a cure for AIDS necessitates continued usage of behaviour change, condom, and male circumcision as prevention measures to reduce HIV transmission. And selecting the most appropriate combination of prevention strategies is critical, especially, given the early contraction of HIV, as early as the teen years.
Studies over two decades indicated that for every five AIDS-afflicted persons, one person is between 20 and 29 years old (CDC, 1993; Smith et al., 1993). And since there is a long HIV incubation period, there is the prospect that older adolescents and younger adults stricken with AIDS, may have contracted the HIV infection as younger teenagers (Brooks-Gunn and Furstenberg, 1990). Sechrist (1997) claimed that first sexual experiences, high prevalence of sexually transmitted infections (STIs), and addiction, are factors that put young people at a higher risk of HIV infection. Furthermore, in the absence of a cure or vaccine for AIDS, the practical option available is prevention.
Recently, the Science journal identified a clinical trial’s finding that antiretroviral therapy (ART) lessens heterosexual HIV transmission, as its ‘Breakthrough of the Year’ 2011. I want to now review this finding to see how Science arrived at this decision. Jon Cohen, writing in Science, pointed out that for decades HIV/AIDS researchers have questioned whether ART applied in the treatment of HIV, also, had a secondary effect of reducing HIV transmission. Some researchers felt that this conclusion seems feasible as ART reduces HIV levels, resulting in less infectiousness among the HIV-infected; nonetheless, others felt that this secondary effect of ART still requires evidence-based verification.
In pursuing this verification, Cohen described the results of the HIV Prevention Trials Network (HPTN)’s $73 million 052 clinical trial on ART; In May 2011, the 052 clinical trial showed that ART decreased heterosexual transmission risk by 96%; the finding also demonstrated that treatment as prevention decreases the spread of HIV. The import of this finding will have huge consequences for upcoming responses to HIV/AIDS.
Impressed with this finding, U.S. President Barack Obama introduced the “AIDS-free generation” plan, that presents treatment as prevention as the plan’s core foundation. Nevertheless, James Shelton, writing the editorial for the same issue of Science, pointed to the significant challenges that ART programming as treatment may endure in preventing HIV transmission. These challenges could include, in Shelton’s terms, the following: high risk infected and uninfected populations, early infectiousness, adherence matters, drug resistance, risk costs, drug toxicity, soaring costs, and problems in reaching the majority-at-risk populations. Shelton believes that the central prevention programs as behavior change, male circumcision, and condoms must complement ART treatment as prevention, and they should not be endangered in the process of using ART treatment as a prevention intervention strategy.
These are significant misgivings that Shelton raised in his editorial. At the same time, there is still no cure for AIDS. Given that we can address the institutional review boards’ concerns and other ethical matters, it then becomes critical to see ART treatment as part of prevention programming to decrease the spread of HIV.
Prem Misir

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