Ingrid Hein

October 14, 2016

Test-and-treat care for HIV, in which antiretroviral therapy is started immediately after diagnosis, is only beginning to become policy, despite a lot of evidence showing that it reduces transmission, experts said at the Controlling the HIV Epidemic with Antiretrovirals Summit 2016 in Geneva.

A sobering example of just how behind policy is was relayed by Brian Williams, PhD, from the South African Centre for Epidemiological Modelling & Analysis.

He described how, when he was driving through the city of Johannesburg this past summer, he stopped for a man begging on a street corner, holding a sign that read, "I'm HIV positive, please help."

Dr Williams gave the man some money and encouraged him to take his medication. The man told him he would be glad to take medication if he had some, but explained that "my CD4 count is above 500, so they won't give it to me."

 
That man on the street knew he should be on antiretrovirals fighting the disease. The country only figured that out last month.
 

"That man on the street knew he should be on antiretrovirals fighting the disease. The country only figured that out last month," Dr Williams told Medscape Medical News.

Until a few weeks ago, patients in South Africa needed a CD4 count below 500 cells/mm³ to qualify for antiretroviral therapy, but in September, the health minister announced that South Africans living with HIV will be able to demand treatment as soon as they are diagnosed.

Although relieved, Dr Williams says he is baffled that it has taken so long for policy to catch up to research.

"We have about 3 million people that need to get started on treatment," he explained, "so it's not going to happen overnight. But honestly, we should have been doing this 10 years ago."

The recommendation to treat HIV-positive people immediately after diagnosis, "even if they feel healthy," was made by the World Health Organization just last year, as reported by Medscape Medical News.

It came after the publication of two large randomized controlled clinical trials — the START study and the TEMPRANO study — which both demonstrated that early treatment with antiretroviral therapy is the best way to boost immune recovery and prevent clinical events.

 
We should have been doing this 10 years ago.
 

However, evidence that early treatment works was available before these clinical trials, Dr Williams explained. Julio Montaner, MD, a pioneer of early treatment from the BC Center for Excellence in HIV/AIDS in Vancouver, British Columbia, Canada, was involved in several studies showing that early treatment and adherence led to decreased transmission in the Downtown Eastside neighborhood.

He was also involved in a 2006 study that argued that antiretroviral therapy reduces the spread of HIV (Lancet. 2006;368:531-536), and in a 2010 review that recommended that therapy "be considered for asymptomatic patients with CD4 cell count >500/µL," as well as for all symptomatic patients (JAMA. 2010;304:321-333).

"Let's not fool ourselves," Dr Montaner said during his opening statements at the conference. This struggle is "a continuum."

There is a tremendous opportunity with the 90-90-90 targets, "but 2020 is just around the corner," he told the audience. "We don't have a lot of time to spend navigating or worrying about our own agendas."

Merging Status and Treatment With Metrics

Dr Williams said he agrees that individual agendas are hindering progress. "The prevention people and the treatment people are fighting with each other," he pointed out.

It is important to look closely at the data, and 90-90-90 emphasizes that. "You need to link awareness of status and treatment together," he explained.

In South Africa "we're not too far off," he added. Currently, 90% of people know their status, 90% of that 90% (or 81% of those infected) are receiving treatment, and, of that 90%, 72% are virally suppressed.

"But as Bill de Blasio, the mayor of New York, said, 'We have to keep going until we get to 100%'," Dr Williams explained. "And he's right."

 
We were terribly wrong to wait to treat.
 

"We haven't really linked testing with follow-up. We were terribly wrong to wait to treat," said Reuben Granich, MD, from the International Association of Providers of AIDS Care in Washington, DC.

A 2009 study by Dr Granich, Dr Williams, and their colleagues, which concluded that treatment should be immediate, caused an uproar (Lancet. 2009;373:48-57). At that time, eliminating risky behavior was thought to be the easiest way to prevent transmission, Dr Granich recalled.

"Now we know we should offer immediate treatment. This really represents a paradigm shift," he added.

Epidemiologic information is crucial to the achievement of 90-90-90 goals, Dr Williams stressed.

Currently, Malawi is the only country in Africa that has a good patient-monitoring system, he noted. There, clinics report quarterly on the number of people who start antiretroviral therapy, the number on therapy, their viral loads, and the number of patients who have died, been lost to follow-up, transferred out, or defaulted.

The monitoring system for patients with HIV is modeled on the country's system for monitoring tuberculosis. Each quarter, every clinic is visited by Department of Health staff, who go through the data, identify and deal with problems that arise, and offer help, support, encouragement, and advice.

Shifting Denominators

Metrics are important to track progress, but Dr Granich expressed concern about how truthful the numbers will be when they are not systematically tracked. "Countries are shifting their denominators. That's how they will present with better percentages to meet the 90-90-90 targets," he explained.

"Let's say I have 50,000 people living with HIV in my country," he hypothesized. "To shift denominators, I will only look at the HIV-positive patients we've been able to find, which is about 15,000, or 20%. Then — we don't really track viral suppression very well — but, look, here's a small cohort where 80% were virally suppressed. Now I'll just say I diagnosed 90% and all are on ART."

The scenario might be an exaggeration, Dr Granich acknowledged, but it brings the point home.

We need to come up with a new way to look at things, he said. "We invest all these resources to get people to have tests and then we lose them. We have to pay attention."

The chronic treatment of HIV means that a long-term commitment to a patient is needed. It could be 40 years or more, he pointed out.

"You wouldn't tell someone they have diabetes and then not follow-up," Dr Granich said. "The philosophy that you're responsible to help that person for the duration of their infection is kind of new, and it needs to be better stated."

Dr Williams, Dr Montaner, and Dr Granich have disclosed no relevant financial relationships.

Controlling the HIV Epidemic with Antiretrovirals Summit 2016. Presented October 13, 2016.

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