Higher success at a higher count

This week over 4 000 South Africans will meet in Durban at the bi-annual national Aids conference.

At the same time, thousands of kilometres away – on the other side of the Atlantic – more than 30 heads of state and governments will gather at the UN High Level Meeting on Aids in New York.

The political declaration coming out of the UN meeting is supposed to serve as a blueprint for the global response to Aids in the next decade.

As one of the countries most affected by the pandemic, South Africa has a responsibility to take the lead in ensuring that an ambitious declaration is adopted.

South Africa’s HIV response has been a regular source of headline stories over the years, for a long time during the Thabo Mbeki era for the wrong reasons – but more recently because the country is at the forefront of finding new ways to tackle HIV and tuberculosis.

In Durban this week, at the 5th South African Aids Conference, delegates will share details on the groundbreaking HPTN 052 trial which ended last month, and which for the first time offers real hope in preventing the further spread of HIV.

Aids researchers announced that the study, conducted in nine countries including South Africa, proved that people living with HIV and on antiretroviral treatment were much less likely to transmit the virus than those not taking the drugs. The study was terminated four years ahead of schedule as the results were so dramatic.

It found that HIV-negative men and women whose sexual partners were HIV positive were almost completely protected from transmission of HIV if the partner took triple-therapy antiretrovirals (ARVs).

The immediate significance this news has for South Africa is that it is urgent to scale up treatment to break the back of HIV and TB.

South Africa needs to increase HIV testing and ensure that all people infected with HIV start treatment as soon as possible.

The Health Department is under pressure to urgently adopt the World Health Organisation (WHO) HIV treatment guidelines which recommend that anyone with a CD4 count under 350 starts on ARVs.

Currently, anyone with a CD4 count (measure of immunity) below 200 is placed on triple therapy ARV treatment. Pregnant women and those co-infected with tuberculosis and a CD4 count below 350 are also immediately started on treatment.

Health Minister Dr Aaron Motsoaledi shared some grim statistics in his budget speech last week. Although South Africa comprises 0.7 percent of the world’s population, the country is carrying 17 percent of the world’s HIV/Aids burden.

South Africa has the highest TB infection rate in the world, and the highest TB and HIV co-infection rate of 73 percent.

At least 35 percent of child mortality and 43 percent of maternal mortality are attributable to HIV and Aids and one in three pregnant women at public antenatal clinics are HIV-positive.

“Surely this needs very serious and extraordinary measures,” said Motsoaledi.

He then added: “We are looking forward to the day, not far away, whereby commencing the treatment at a CD4 count of 350 will be universal and not only for specific target groups. This is imperative in the light of new research released recently that starting ARVs very early has given huge benefits for prevention of HIV and for protecting individuals against TB.”

Motsoaledi has often lamented that there is no way that South Africa can treat its way out of this pandemic. That was before the HPTN 052 results.

Motsoaledi has already tasked his officials with costing the expansion of ART access to everyone with a CD4 count below 350. It is critical that this is not a long, drawn-out exercise, and that it happens very quickly in the light of the fact that the country will be receiving a sizeable amount of money from the Global Fund to fight Tuberculosis, Aids and Malaria.

Recently a number of South Africa’s foremost HIV advocates sent a letter to, among others, President Jacob Zuma and Motsoaledi, calling on the country to again take the lead this week when the UN meeting takes place.

It urges South Africa to continue to set an example with its approach to tackling HIV and TB by publicly committing to ambitious national targets, calling on other African states to do the same and pushing developed countries to commit to ambitious global treatment and funding targets. Sources have expressed some concern that South Africa’s voice has been silent in the African bloc during consultations in the run-up to this week’s meeting, leading to the draft declaration being somewhat conservative.

The letter – drafted by Médecins Sans Frontières (MSF), the Treatment Action Campaign (TAC), Section27, the World Aids Campaign and the Aids and Rights Alliance of Southern Africa – urges South Africa to use this important opportunity to ensure “we do not miss the chance to build on the successes achieved over the last decade and combine these with the promising new scientific developments to begin to turn around the HIV epidemic”.

HPTN 052 is not the only study pointing towards treatment being the future of HIV prevention.

Several observational studies have shown that early ARV treatment is unlikely to be harmful while others show the benefits. The US and EU countries are already changing their guidelines to initiate treatment at a CD4 count below 500.

Further observational data from a Cape Town township has also shown that if many HIV-positive people in a community with high TB prevalence are on ARVs, there is a low TB transmission rate. HPTN 052 also showed reduced cases of extra-pulmonary TB in those who started treatment at a CD4 count between 350 and 550.

Two randomised controlled studies are currently ongoing and should help to answer once and for all whether ARVs should be offered to all people with HIV.

But there is a growing international sentiment that the world cannot afford to wait in the light of the HPTN 052 results.

It is no secret that there will be significant cost implications of offering ARVs to all people with HIV, but reduced new infections may help offset the long-term costs.

Dr Gilles van Cutsem, medical co-ordinator for MS South Africa, is unequivocal that the HPTN 052 study confirms that getting people on treatment sooner could break the back of the pandemic.

“Here in Khayelitsha, we are seeing early signs that HIV infections have been on the decline since the introduction of large-scale HIV/Aids programmes that have put many people on treatment. This means that treatment is a form of prevention,” said Van Cutsem.

“ARVs knock down the levels of HIV in the blood – individuals benefit because they avoid getting opportunistic infections, while the community benefits because fewer people get infected.”

He said the New York meeting could only be a success if governments wrote a blueprint to speed up and intensify the response.

So while the mantra has always been that the world cannot afford to treat its way out of this pandemic, ARV treatment may offer the one real hope of making headway on the prevention front. And in the long run the results will not only be measured against the decrease in dollars spent now, but the human lives saved. New York and Durban need to take the first real steps towards making this a reality. – Health-e News Service