“In 1985, I managed only dying patients,” Dr. Myron Cohen told a packed room in the Russell Senate Office Building today. By 1995 that had changed, he added. In 2013, he continued, people with HIV stay alive and healthy with one pill a day.
Cohen, along with fellow panelists Dr. Chris Beyrer, Dr. Laura Guay, and Dr. Renee Ridzon came to Capitol Hill this morning to answer a question with a review of advances that have changed the landscape of global health: “Where are we in ending the AIDS epidemic? An update on the science.”
The answer, Cohen and the other physician researchers, who spoke at a Senate briefing this morning and will deliver a second briefing from 2 to 3:30 this afternoon at the House Cannon Office Building, depends on how fast the interventions that have been proven to prevent transmission of HIV and save lives are made available to all who need them.
With 32 years of confronting the HIV epidemic, Cohen has seen advances come with painstaking slowness. The prime example: The HPTN 052 study, which proved that treating HIV with medicine not only saved lives but prevented transmission. That study took more than 20 years to yield its groundbreaking answer, and to be named science breakthrough of the year. He has also seen change come fast, as answers built on answers: Showing the impact of treatment on reducing community wide HIV prevalence, in allowing people to return to work, in increasing life expectancy, and proving, he said that the time to invest fully in applying science is now.
What began as a charitable response, he said, has become something else as well: “It is the most economically sensible and viable thing to do.” That means getting treatment for HIV to everyone who needs it. According to new World Health Organization guidelines that recommend starting treatment earlier in the illness, and increased eligibility for children and others at greater risk of harm or of transmitting the virus, that number just got bigger. Eventually though — whether sooner or later, the number of people who will need treatment for HIV currently stands at about 34 million — the number of people who live with the virus.
That, panelists reiterated, is why speed is essential now.
“Everything he said is true,” said Dr. Laura Guay of the Elizabeth Glaser Pediatric AIDS Foundation and The George Washington University (GWU) School of Public Health and Health Services. She described the original treatment-as-prevention intervention — recounting the impact of giving antiretroviral medicine to HIV-infected pregnant women in preventing transmission of the virus to their babies as it brought rates of children born with the virus from upwards of 40 percent to less than 4 percent. But, she pointed out, children who do have the virus are still largely missing the benefit of treatment expansion among adults; just 34 percent of the children in need are getting antiretroviral medicine. The treatment gap between children and adults will only grow, Guay noted, with the new WHO guidelines, which had recommended antiretroviral treatment for all children under the age of two, and now recommend treatment for all children under the age of five. “This means we have to concomitantly increase efforts,” she said.
Ditto for medical circumcision, said Dr. Renee Ridzon, who followed Guay to describe the current status of an intervention targeting men, but that, she pointed out, by preventing men from acquiring HIV, protects the women in their lives as well. About 20.3 million men would need to be circumcised to make the greatest possible use of that one-time, proven HIV intervention, she said, “That is a lot of foreskins that need to be removed.” But advances in efficiency, including training nurses to perform the procedure, as well as advances in technology with one nonsurgical device, Prepex having recently received prequalification by WHO, and another nonsurgical device likely to be approved by the end of the year, she said, can make what should be done possible.
So where are we in ending the AIDS epidemic? The final answer gave the missing piece — it is not just speed, but scope that will bring the epidemic under control Dr. Chris Beyrer, of Johns Hopkins and president-elect of the International AIDS Society said.
“I’m going to talk to you about some of the undone work at this extraordinary moment,” he said. “We’re really not there yet for a group of people who are sometimes called key populations, sometimes called Most At Risk Populations.”
That includes men who have sex with men, people who inject drugs, people who make a living through commercial sex, transgender women and women of color, people who because of what they do, or simply who they are, are both likelier to be exposed to HIV, and less likely to be able to access treatment and care, Beyrer said. It is a double jeopardy that is seeing rates rise in Northern Africa and Eastern Europe where injecting drug users are likelier to be punished than helped. At the same time the marginalization of men who have sex with men is a factor in America’s epidemic, as well as a still uncounted impact in sub-Saharan Africa.
The good news, Beyrer said, is that activist movements spurred by the impact of HIV among gay and transgender people have gathered force across Africa, Beyrer said, and support for their movements are gathering among donors and diplomats, who are, at least, beginning to speak of full access to testing and treatment for all as a goal.
“The wonderful news,” Beyrer added, “is that we have the tools to really turn this around.”
The briefings were co-sponsored by amfAR, the Foundation for AIDS Research, the Elizabeth Glaser Pediatric AIDS Foundation, and the Center for Global Health Policy, which produces this blog.