HIV and ID Observations

Answer:  Put everyone on treatment.

Conspicuously absent for decades, the prevention part of the “when to start antiviral therapy?” question has now moved front and center in two recent papers: 

• In this week’s Lancet, a group from the WHO estimated what would happen if there were annual universal HIV testing, and then immediate treatment for all found to be positive.  They used South Africa — the country with the highest number of HIV cases — as a test case, and assumed heterosexual transmission of HIV.  After going through the usual gyrations required in such mathematical models, they found that such a treat-everyone strategy would shift the HIV epidemic in South Africa from its current (dismal) phase to an “elimination phase” —  with an ending to the epidemic feasible by 2020.
• This summer, researchers from Vancouver (of course from their Excellent “Centre for Excellence”) published a paper with largely similar findings — this time applied to an epidemic that is more typical of developed countries, predominantly made up of gay men and injection drug users.  As with the WHO/South Africa paper, there would be a high up-front cost of expanding therapy, but ultimately costs would be lower because of averted infections.

The treatment-as-prevention theme, of course, got off to a roaring start this year when the Swiss National AIDS Commission issued a statement saying that people with HIV who are adherent to antiretroviral therapy, have undetectable plasma viral loads, and have no sexually transmitted infections are not infectious to others.  

Very bold — especially for a country famous for chocolate, watches, and fondue.

While the certainty of this statement struck some as extreme, and others as bordering on arrogant  — and this single case report is an example of how doctors should “never say never” — the principle behind the Swiss statement was sound, and quite helpful in getting the conversation started.  Treatment can be prevention, and this is something we should discuss with each of our patients when reviewing the pros and cons of going on therapy.