November 30th, 2008

How to End the HIV Epidemic

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.

2 Responses to “How to End the HIV Epidemic”

  1. Ndubuisi Edeoga says:

    Most HIV/AIDS patients that I have had the opportunity to meet with here in the US, have superior knowledge about their disease. They scourge the internet and read up anything they see about their medication, and possible “new cures”

    Most of these patients too have gone to great lengths to keep their virus suppressed, borne the brunt of varied side-effects, and have kept the faith.

    Reading these essays (published) about use and non use of condoms, I will advocate more care and rigor before sending out publications out to the mad world of the net. Many HIV/AIDs people are waiting for the great new cure ……magic bullet……and they might be tempted to go with the tide of new findings before they are validated.

  2. med says:

    i hope the this is a sure cure. this guys really need help. just imagine you love one dieing in you hands not because the money isnt there but because there is no solution. it kills the reason to live.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.