Test and treat – is it real for HIV?

A recent study by the World Health Organisation suggests that HIV could be eradicated from the planet within 10 years. But is this a realistic prognosis? NICOLE GOOCH reports.

LAST year, a team of World Health Organisation (WHO) scientists published a study in the British medical journal, The Lancet, claiming the HIV pandemic can be brought to an end within 10 years.
They claimed that there would be universal annual HIV testing followed immediately by treatment for patients who tested positive, regardless of the state of their immune system.
Dubbed the “test and treat” approach, it had been hailed as an historical opportunity to eradicate HIV from the surface of the planet, and was a highlight of this year’s international AIDS conference in Vienna in July.
It also featured on the agenda of the Australasian HIV/AIDS conference in Sydney last month.
But, Prof Susan Kippax from the social policy research centre at the University of NSW said the study’s mathematical modelling was unrealistic.
“WHO is misguided,” she told New Matilda bluntly.
The study was based on evidence, observed among heterosexual couples in which one partner was HIV positive and the other was not, that HIV anti-retroviral therapy reduced patients’ viral load, thus lowering the likelihood of HIV transmission.
It recommended annual universal voluntary testing of all people over the age of 15; the authors argued that, in the long term, this approach was the most cost-effective way to combat the spread of the virus.
Kippax termed the strategy a “silver bullet” and said she was concerned about the increasing dominance of biomedical prevention in public health at the expense of political and behavioural change.
She argued that all biomedical prevention tools, be they condoms or clean needles, required behaviour change and the right context in order to be effective.
In other words, the drugs were not enough.
Australia cottoned onto this early with one of the most innovative and successful HIV responses in the world.
Since the mid-80s, federal and state governments had worked on a bottom-up approach with community organisations, mixing biomedical prevention and social change.
Law reform, such as the decriminalisation of homosexuality in NSW in 1984 and the controversial introduction of needle exchange programmes, played a crucial role in averting a serious epidemic.
However, Kippax said the new focus on biomedical interventions would give governments “a beautiful reason for not having to address sex and drugs”.
And, while Sean Slavin, assistant director of the national association of people living with HIV/AIDS (Napwa), said Australian activists, scientists and government representatives worked in a cooperative fashion, he was also worried by a tendency “to always race towards the medical intervention”.
His concern was that even in NSW, the “treatment as prevention” debate could edge towards a public health approach that put the welfare of individual patients second to the benefit of the general population.
To start a patient on antiretroviral therapy was to make a considerable commitment, Slavin said. “It means taking medication everyday for another 40 or 50 years, and the side effects are often people’s first experience of illness in relation to HIV.”
Pressuring patients to start early might also mean poor adherence to the treatment regimen, which risked producing a resistant strain of the virus – “both a problem for the individual and the community”, Slavin said.
For now, the lead author of the paper in The Lancet, WHO HIV/TB medical officer Dr Reuben Granich, said WHO was only focused on increasing testing and counselling worldwide and ensuring that all people, whose immune system was failing, had access to treatment.
In fact, WHO avoided using the term “test and treat”, as it had become associated with testing everybody and treating them immediately, which angered human rights activists, Granich said.
He was adamant WHO would never recommend a mandatory or coercive approach, but he did not think “anyone will argue that it is a bad thing for people to know their status, so they can access anti-retroviral therapy to save their lives”.
Here, Kippax raised some concerns.
She told New Matilda that “many people resist being tested in the developing world, since they are terrified of finding out if they are HIV positive because of stigma”.
In PNG, Maura Elaripe, founder of Igat Hope, the umbrella NGO for people living with HIV, was forcefully sterilised because of her HIV positive status.
In a country with high levels of gender-based violence, Elaripe said it was “very hard for women to come home after a routine test and tell their partner they tested positive”.
Doctors recently told Elaripe they were no longer registering new patients on antiretroviral therapy because they were worried PNG might run out of treatment supplies.
For them, the risk of a patient developing drug resistance, while on a treatment break, was too dangerous.
The Global Fund to fight AIDS, tuberculosis and malaria last year rejected PNG’s application for HIV funding based on its stringent accountability criteria.
It would provide another two years’ worth of antiretroviral therapy for PNG’s 6,500 patients currently receiving treatment – but not for new cases.
The PNG government had, however, stepped in with a promise of K6 million for medicines and had applied to the next round of Global Fund money.
By contrast, Australia suffered from relatively little HIV stigma and provided easily accessible testing and treatment, yet infection rates had increased between 1999 and 2008, particularly in Victoria and Queensland.
Kippax said this was most likely due to a decrease in prevention funding and she feared countries such as PNG with limited resources would have even more trouble resisting the lure of the “prevention is treatment” slogan, choosing instead to invest all their money in treatment.
But, “unless money is spent on prevention, we are just going to see HIV prevalence rates go up, country after country, and more and more people on treatment – and countries will go broke”, she said.
Slavin agreed that all options needed to be investigated, both in Australia and overseas.
“This is just another instance in which we need to have a debate, and keep our minds focused on both the history of the epidemic, and the human rights of the people,” he said.
At the Australasian HIV/AIDS conference last month, the scheduled debate took place on the relevance and logistics of implementing anti-retroviral therapy as prevention in the region.
And, a world away from messages of hope and progress delivered at conference plenaries, Elaripe, tired of chasing bureaucrats to make sure her special HIV line 2 drugs arrive on time, worries about what the future holds for people living with HIV in PNG. – newmatilda

*Nicole Gooch is a freelance journalist from New Caledonia and the island’s Australia correspondent for its French newspaper. She used to work in public health for the secretariat of the Pacific Community.