WHO’s HIV/TB update latest move toward treatment as prevention

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The potential for antiretroviral medicine to reduce transmission of HIV and tuberculosis has been demonstrated, but the challenges of using treatment to prevent infection will need to be tackled country by country, and with focus on people for whom it will have the biggest impact, the latest bulletin on HIV treatment from the World Health Organization says.

WHO’s June 2012 Antiretroviral Treatment as Prevention (TasP) of HIV and TB Programmatic Update is the latest of a series of documents the organization says will lead to a completed set of guidelines on treatment and prevention in July 2013. The organization also plans to release new recommendations in time for the July International AIDS Conference, addressing the preventative use of antiretroviral medicine by people who are uninfected but potentially exposed to HIV, including those involved in commercial sex work, in ongoing relationships with infected partners and men who have sex with men.

In the wake of evidence that antiretroviral medicine reduced transmission in couples from HIV-positive partners to uninfected partners, WHO has updated its recommendations for treatment given to HIV-positive pregnant women and issued new guidelines for testing and treatment of couples. WHO’s April 2012 Guidance on Couples HIV Testing and Counselling, including Antiretroviral Therapy for Treatment and Prevention in Discordant Couples include strongly recommending that people living with HIV in ongoing sexual relationships with uninfected partners be offered antiretroviral therapy to reduce HIV transmission, earlier than had been previously indicated for their own health. WHO’s Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants, also released in April 2012, suggested a regimen of three antiretroviral drugs be given to all HIV-positive pregnant women and potentially continued for life.

The latest update notes that greater access to antiretroviral medicine has been shown to lower tuberculosis infections and deaths, and has indicated that giving the drugs to individuals within two years after their infection would lower new tuberculosis infections by 63 percent. The update also points out that the understanding that treatment can lower transmission of HIV and TB has been around for nearly 10 years and that some countries already have included recommendations for earlier treatment and for the use of medicine to prevent infection in their guidelines.

The update cautions, however, that while preventing new infections will save money as well as lives in the long term, sparing resources for that purpose remains a luxury for many countries. “Further economic and epidemiological modelling is needed to refine projections of the expected resource needs and public health impact when these recommendations are planned and implemented in different settings,” is how the document puts it.  Other challenges include large numbers of people in countries hardest hit by the epidemic who are infected and don’t know it, as well as economic and discriminatory barriers to treatment. Communities will have to be included in plans to use treatment as prevention, the document points out, adding that while “many programmes recognize this principle in theory, its practice is challenging and further efforts are needed to implement this essential aspect of a successful HIV response.”

And, the document says, questions of how countries will prioritize who will get access to treatment as prevention and how it will be made available, will need to be asked and answered locally.

WHO is organizing a meeting to review the use of treatment as prevention to take place by satellite with panelists that will include United States Global AIDS Coordinator Eric Goosby, as well as representatives from Malawi, Zambia, South Africa, Cambodia, and the United Kingdom on Sunday, July 22 at the 2012 International AIDS Conference.

 

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