In the middle of the first week of the U.S. government shutdown, the meeting of the Scientific Advisory Board for the President’s Emergency Plan For AIDS relief was a respite from the void, as clinicians and researchers discussed the unmet needs of adolescents, men who have sex with men, people who inject drugs, and people involved in commercial sex transactions. Then the event turned to a question that remains at this point, a philosophical one: “How, in a resource poor setting, would you treat an HIV patient with no symptoms, and a still strong immune system?” and it was debated by two prominent HIV researchers, with two different points of view.
The first was Dr. Mike Cohen, lead investigator of HPTN 052, the study that proved treating HIV also prevents transmission of HIV, and he tackled the question as broadly as it was intended, not for one patient, but for all of them, who, if he could, he indicated, he would treat. The time for studies on this question has passed, he said. When clinicians stop sending mixed messages on the value of immediate treatment, patients will stick with it. The cost benefits, in reduced infection rates, healthier patients and streamlined programs are in favor of early treatment, he argued, as are public health and patient benefits. Yes, logistical challenges to immediate treatment for everyone exist, but they exist only to be overcome. “Otherwise, we’re revisiting pre-Durban logic,” he added, referring to the not so distant past when logistical challenges were weighed as reasons not to act quickly to roll out treatment in resource poor countries at all.
Wafaa El-Sadr, of Columbia University and the International Center for AIDS Care and Treatment Programs who has developed a multi-pronged approach to tackling HIV as well as TB among populations with the least access to health care, went next.
“We must continue to ask questions and seek answers,” she said. In the numbers of people who have received immediate treatment in resource poor settings, and in the long term impact, “We are just seeing the tip of the iceberg.” We’re debating this, she reminded the audience, because we don’t know the answer. “Which begs the need for a study.”
In the end, it was hard to tell who won the debate, with some jokingly citing a preference for one debator’s demeanor over the other, and some stolidly practical (“I don’t think enough of this discussion has been informed by the fact that we’re living in a resource poor world,” said one). But in a deadlocked week, the debate brought the room to life.
He started by showing a picture of his daughter. She was a toddler when Cohen joined the University Of North Carolina School Of Medicine in the early 1980s, and the recorded AIDS epidemic was also in its infancy. It was killing thousands across the country and hundreds in Chapel Hill, a small town that saw a big epidemic thanks to massive blood donation efforts to treat the thousands of hemophiliacs who flocked to the town to benefit from the hemophilia treatment research spearheaded by the university at that time. By 1985, 10 percent of admissions to the hospital were for AIDS in Chapel Hill.
He and colleagues at Chapel Hill began to ask if HIV treatment could also work to prevent transmission of the virus shortly after the first treatment, AZT began to show results in 1987, Cohen recounted. They got their answer nearly 30 years later when the HIV Prevention Trials Network 052 study showed that HIV treatment lowers the risk of transmission to non-infected partners by 96 percent.
Now we know, said Cohen, that not only does universal HIV treatment prevent infection, it boosts productivity and GDP in the hardest hit countries.
Treatment is the bridge to the future, he told this gathering, not far from where the Golden Gate spans the channel between the San Francisco bay and the Pacific Ocean.
In the beginning, “there was no bridge, there were just wards with everyone dying,” he said. Before 1987 there were no drugs and everyone died, and before 1996, there were only three drugs available. Now, we have over 30 agents, he said. He expects that 2015 will be another point in the bridge to an AIDS-free generation.
He ended by showing another picture of his daughter, today a young woman with children of her own, who, he said, will perhaps grow up to see the beginning of an AIDS-free generation.
“Now is the time to redouble investments in research and implementation” Cohen said. “Failure is absolutely not an option.”