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TEN years ago, when the International AIDS Society (IAS) met in Durban, there was a lot of fractious debate between those who wanted to spend money on treating the sick and those who thought that stopping the epidemic was more important. It took another six years to realise that you might be able to do both. Suppressing the virus in someone’s body clearly saves his life, but it ought also to make him less likely to pass on infection. The latest evidence that this might be true was released at this year’s IAS meeting, held in Vienna on July 18th-23rd.
The meeting brought news of another long-sought breakthrough: a vaginal microbicide that will allow women to protect themselves from men who do not wear condoms. There was also much hand-wringing about money, as governments and taxpayers in rich countries feel the pinch. But even here there was a refreshing honesty, as the international agencies charged with combating the disease queued up to suggest ways of doing more with less. That businesslike approach was apparent, too, in discussions over focusing treatment on those who are most at risk.
As the meeting opened, it was announced that a study by Julio Montaner, a researcher at the University of British Columbia, had shown that ramping up treatment in that Canadian province halved the rate of new infections. Dr Montaner’s study, published in the Lancet, was the strongest confirm!!ation yet that treatment and prevention are two sides of the same coin. The study showed that the annual rate of infection in 1996—the year when the modern regime of highly active antiretroviral therapy (HAART) was introduced—had, by 2009, fallen by 52%. During that period the number of people on treatment rose by 547%.
Of course correlation is not causation. But the rates of other sexually transmitted diseases did not fall, suggesting that British Columbians are just as promiscuous now as they were then. Nor did the rate of hepatitis C alter, suggesting that people there are injecting just as many drugs with just as many dirty needles. And a detailed look at the numbers shows that the biggest falls in infection rates were during periods when the rise in HAART was fastest. The study, together with previous work showing that HAART reduces the rate of transmission between discordant couples (in which only one partner is infected) by more than 90%, points to the conclusion that widespread use of antiretroviral drugs helps to explain the 17% fall in the rate of new HIV infections seen around the world between 2001 and 2008.
The new microbicide, too, depends on an antiretroviral drug—tenofovir. Previous attempts to make vaginal microbicide gels that block the passage of HIV have involved long-chain molecules called carrageenans, thickening agents found in seaweed. It was hoped these would tangle the virus particles up.
That strategy failed. Instead, Quarraisha Abdool Karim and her colleagues at the Durban-based Centre for the AIDS Programme of Research in South Africa tested a gel that contains tenofovir. Their study, published in Science on the second day of the meeting, looked at rates of infection with HIV over three years in two groups of women. Those in one group were given the microbicidal gel. Those in the other were given a placebo. The rate of infection in the first group was almost 40% less than in the second; the gel’s most diligent users saw a reduction of over 50%. And no adverse side-effects were observed.
Nor was another fear realised. Tenofovir is widely used, and people are understandably concerned about the emergence of resistant strains of HIV. Some opposed tenofovir’s use in a microbicide because they worried that it would encourage the emergence of such resistance. Dr Karim and her colleagues have, so far, seen no sign of this in women who were infected.
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On the question of who pays for all these drugs, the feeling at the meeting was glum but not despondent. Global health budgets have done well in the past decade, in particular those dedicated to AIDS. Such rapidly rising expenditure would surely have come under sharper scrutiny even without the prompting of an economic crisis. With it, the increases have come to a sudden halt (see chart).
No one likes to have their cash cut off but it does concentrate the mind wonderfully on doing more with less—especially with regards to the additional costs that come with treating patients. As is well known, drug costs have already declined dramatically. Treatment that in 1995 cost $10,000 a year is now less than $100. But the other annual costs of delivery—staff, infrastructure and so on—are about three times this amount.
The consensus at the conference seemed to be to take things out of the hands of expensive doctors and give them to nurses or, better still, paramedics. In part that means more training; it also means simpler treatment regimes (fewer pills per day); and it means changing expectations about who will do what. Christoph Benn of the Global Fund, an international body formed to fight AIDS, tuberculosis and malaria, reckons that this could bring the additional, non-drug costs down to $100 per course of treatment per year. That would please donors.
Another change, proposed by Michel Sidibe, head of UNAIDS, the United Nations body charged with combating the epidemic, is to be more honest about who is at risk. The history of the disease has created a numbing political rhetoric around it. AIDS was first recognised in homosexuals, is spread by prostitutes and drug addicts, and is found above all in poor, African countries. When people with AIDS were demonised in the early days of the disease, the strategy was to repeat the mantra that almost anyone could get infected. Technically, this is true. In practice, however, some people are at much greater risk, and they may be ill-served by such political correctness.
Although the roll-out of drugs to the infected has been a great success, with 5.2m people of the poor being treated, Dr Sidibe fears things are slowing down. His solution is to seek out those at greatest risk of infection, such as the growing numbers of Russian drug users, and offer prompt treatment rather than waiting for them at clinics. He wants the number of people starting treatment each year to exceed the number that are newly infected. At the moment the ratio is 2:5. He will not say when that will happen, but he believes that universal treatment is possible.