When Francoise Barre-Sinoussi, Director of the Louis Pasteur Institute in France and winner of the Nobel Prize in 2008 for her discovery of HIV, first isolated the HIV virus in 1982, she had no idea she had stumbled onto the greatest epidemic of our time.
“Initially, we thought only a small group of people were affected by the disease,” Barre-Sinoussi told Al Jazeera. “Very naively, we did not realise the magnitude of the epidemic.”
She was right to be wary. Since then, 60 million people have been infected with HIV and over 30 million have died, akin to half the population of the United Kingdom.
But Barre-Sinoussi was not easily disheartened. “I believe in science. If not now, in the long term, we will find other strategies. My dream is to see the end of HIV before I die.”
Her belief was not unfounded.
The dawn of 2012 brought with it the hope of a new breakthrough published in the New England Journal of Medicine in 2011: life-saving anti-retroviral treatment (ARV), the gold standard for treatment of HIV/AIDS will also prevent transmission of HIV to sexual partners with 96 per cent effectiveness.
These “serodiscordant couples”, as they are known, make up 30 per cent of the global HIV burden. This research is considered a game changer. Such high success rates are almost unheard of in scientific literature, so much so that the trial, known as HPTN 052, was concluded prematurely.
“It is a dream for us to have a treatment with the capacity to cure. It means we can use the tools that we already have at our disposal,” Barre-Sinoussi told Al Jazeera.
Treatment as prevention
The treatment as prevention strategy (TasP) has been described by Science magazine as the biggest discovery of 2011, a sentiment echoed by the Time, Lancet and Doctors without Borders. Experts in the field argue it may be the scientific breakthrough of the decade.
“TasP is a beautiful discovery,” Elly Katibara, President of the International AIDS Society, told Al Jazeera. “In the process of treating people, you are doing two jobs.”
Breakthrough in the fight against HIV
In 2005, the Universal Access Pledge was made by every UN member state to provide universal access to HIV prevention, treatment and care for all who need it by 2010. The goal was simple but ambitious: zero new transmissions by the year 2015. Though no “silver bullet” existed for the eradication of this disease, nations were committed to the available treatment and prevention strategies, with the hopes that investment in research would one day yield something more effective.
That time has arrived.
Dr Julio Montaner, Director of the British Columbia Centre for Excellence in HIV/AIDS in Canada and former President of the International AIDS Society, has pioneered research in TasP since the mid-90s.
“We have the opportunity here to change the course of history,” Montaner, told Al Jazeera. “It is within our grasp to see an HIV-free generation in our lifetime.”
HIV or the human immunodeficiency virus, is a sexually transmitted disease that impairs cells in the immune system, known as CD4 cells, leaving the body unable to fight infection. The transition to acquired immunodeficiency syndrome or AIDS occurs when the decline in CD4 cells leaves the body vulnerable to “opportunistic infections”, infections a normal immune system could fight off.
In 1996, 10m people were affected. Despite calls by scientists to provide funds to fight the disease, nations did not act and the epidemic grew exponentially.
Sixteen years later, 34m people are now living with HIV; two-thirds reside in sub-Saharan Africa and more than half are women and children. The fight against HIV has cost billions of dollars and almost $1tn in treatment for AIDS related illnesses, lost productivity and other socioeconomic consequences.
“Treatment as prevention has become the centrepiece of the international AIDS movement,” said Stephen Lewis, a well-known philanthropist and activist who previously served as a United Nations Special Envoy for HIV/AIDS in Africa. “Everyone has been persuaded.”
The world took notice; after results of the study were released, UNAIDS set a goal of treating 15 million people by the year 2015.
The first study to look at the real life applicability of TasP in the global south was published in in March 2012 and the results are promising.
Talk is cheap, but intervention is not.
The Global Fund to Fight AIDS, TB and Malaria, the largest financier in the struggle against HIV, relies primarily on financing from the international community. Funding shortfalls totaling $20bn in 2012, due to G8 countries reneging on previous financial commitments, have forced The Global Fund to freeze financing of existing HIV treatment programmes and decline all new programme requests for 2012. This includes the implementation of TasP.
Number of AIDS cases remains high
On March 27, 2012, Doctors Without Borders released a report outlining the effects of this Global Fund deficit.
“The hit is being felt most acutely by the countries who can least afford it,” Dr Isabelle Meyer-Andrieux, HIV Medical Adviser for Doctors Without Borders, told Al Jazeera.
An estimated one million people are living with HIV in the Democratic Republic of Congo (DRC). As a result of the cuts, the DRC has had to close the doors on its pediatric HIV wards.
“Programmes are losing confidence in future funding and instead of scaling up treatment initiatives based on recent advances, they are scaling back,” Meyer-Andrieux said.
According to UNAIDS, the $20bn invested into the fund would prevent 12.2 million new HIV infections and 7.4 million HIV related deaths between 2011 and 2020. Twenty billion seems a large sum, but to put this in perspective, the US alone spends $1.9bn daily on defence, according to the economist Jeffrey Sachs.
“It’s completely short-sighted,” Lewis told Al Jazeera. “Financing is always available for war and the things that do nothing to improve the human condition, but never for things like global public health.”
Dr Bernhard Schwartländer, Director for Evidence, Strategy and Results at UNAIDS told Al Jazeera that the international community needs “to get away from the cost argument and think of long term investment”.
Politics behind policy change
Lack of funding is not the only obstacle. There is disagreement over when treatment should begin. The clinical stage of HIV is determined by the level of CD4 immune cells in the body, and the World Health Organisation (WHO) Guidelines recommend treatment at a CD4 count of less than 350. If 100 per cent of these patients are treated, it will prevent 20 per cent of transmissions.
“With this goal, we are looking at controlling the epidemic, not eliminating, it,” said Schwartländer.
These guidelines are different from North America and developed countries, where treatment is initiated earlier, at a CD4 count of 500.
“Eighty per cent of these patients with a CD4 500 will be CD4 350 in 3-5 years and need treatment anyways,” said Montaner. “If we treat earlier, we not only prevent illness, but also prevent transmission during this time.”
So why is one treatment level OK in the rich world, while a lower standard is acceptable for the poor?
Dr Ying-Ru Lo with the Department of HIV/AIDS at the WHO sheds some light. “For many low and middle income countries, the WHO guidelines take cost and readiness of the systems into account.”
The reality for patients is that they are being turned away for “not being sick enough” and up to 25 per cent of them will not return for testing.
“Many friends of mine were not eligible for the treatment and either did not return later to be tested, came back in wheelchairs, or came back too late with already concurrent illnesses,” Kenly Sikwese, am HIV positive patient in Lusaka, Zambia, told Al Jazeera.
Dr Myron Cohen, lead author of the groundbreaking New England Journal of Medicine study, says the treatment needs “public health plausibility” in order to “become a reality”.
“We have to find everyone and get them on treatment… this is what the study required,” he said.
But access to testing and treatment is easier said than done, especially in rural areas of sub-Saharan Africa.
“In order to treat, we need to expand testing,” Schwartländer told Al Jazeera. “It is one thing to treat in Vancouver, but when you take this treatment into the middle of Tanzania where there is hardly water and electricity, it becomes more difficult.”
Montaner doesn’t buy this. “It’s about funding again. In these same remote areas, you see people drinking Coca-Cola because of their successful, widespread marketing campaign.” If soda companies can penetrate these regions, he said, health experts can easily do the same.
With the evidence for TasP ushering in a new era in the fight against HIV/AIDS, 2012 opened with a bang. But as March comes to a close and headlines fade, what’s changed? The funding shortage for the new treatment could mean the difference between life and death.
The good news: With dedicated prevention policies, including education, efforts at preventing vertical transmission, male circumcision and treatment, the United Nations announced at the end of 2011 that the epidemic has reached its lowest rates since its peak and over seven million people are on anti-retroviral drugs.
Deaths from AIDS-related illnesses decreased by 21 per cent since 2005 and new HIV infections were reduced by 21 per cent since 1997. Today, more people than ever are receiving treatment, with 6.6 million people on ARV in 2010, an increase of 1.35 million from the previous year.
The bad news: The funding shortages will undermine much of the work that has been done to date.
Montaner recognises the reality of the situation. “At the very least, we should be aiming for 100 per cent coverage for those with a CD4 less than 350, HIV positive mothers to prevent vertical transmission and HIV positive patients in serodiscordant couples.”
Botswana has already implemented TasP, with 80 per cent of HIV patients on treatment, decreasing the rates of transmission by 30 per cent. Even China sees the wisdom of acting earlier, implementing a national treatment as prevention initiative aimed at controlling AIDS by 2015. To this end, over 67 million HIV tests have been conducted in 2011.
2012 may be not the year the international community eliminates HIV, but health experts say it could still be the year where the tide is turned.
“We have a 10-year window of opportunity to control this epidemic before we get to a point where there will be very little we can do,” Montaner told Al Jazeera. “And the longer we delay, the more millions of lives will be lost unnecessarily. This is completely unacceptable. What is the point of having a breakthrough of this nature if it will not be implemented?”
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