CROI 2015: Is 90-90-90 nutty? Studies look at numbers behind getting in care, staying in care, suppressing virus, controlling HIV

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Science Speaks is covering the 2015 Conference on Retroviruses and Opportunistic Infections in Seattle Washington live this week, from February 23-26, with breaking news on HIV research findings and implications.

From the reasons to work with sex workers, to a survey of viral load, to ways to do more with less — and what donors can forget about — last morning of science conference looks at efficiencies and impact . . .

Can efforts to prevent and treat HIV among sex workers alter the course of the epidemic in Africa? They have in Asia, but resources to reach one of the most disproportionately hard hit populations in sub-Saharan Africa fall short because sex workers’ long term contribution to overall HIV rates is underestimated, one of the first speakers here today said. Speaking at the start of the last day of a conference focused on the development and best use of medicines, Dr. Frances Cowan of University College London, who oversees a sex worker centered program called “Sisters with a Voice” was there to argue that involving sex workers in work to fight HIV will maximize the benefits those medicines offer. She reviewed the measures that work: condoms and lubricants, treatment for other sexually transmitted infections, access to contraception, and interventions to reduce harm from injecting drug use for some. When she got to “community empowerment,” though, to which she added “it’s been a UNAIDS best practice,” for years, she also added that she understood “this may sound wooly to some of you.” In fact, she said, analyses have shown “community empowerment” which includes providing safe places for sex workers to meet, opportunities to organize and compensated participation in responses, is linked to lowered rates of HIV, and other sexually transmitted infections. “Proper inclusion of sex workers is critical to 90-90-90.”

That UNAIDS-set goal of 90 percent of everyone infected with HIV knowing it, 90 percent of those being on treatment, and 90 percent of those on treatment having a fully suppressed virus as a result can and has been seen as both dauntingly distant from most current realities, and a humanitarian imperative.

Cowan’s talk was followed by a series of presentations this morning highlighting both perspectives.

Dr. David Maman of Médecins Sans Frontières discussed results of three household surveys in high HIV prevalence settings in Malawi, South Africa and Kenya, that showed, among other findings, that men identified with HIV had viral counts about five times higher than that of women with HIV. “It suggests the importance of targeting men,” he said, “to protect women.”

Workplace HIV testing programs may be one way to find the missing men missed in home surveys and marketplace mobile testing, Simbarashe Takuva of the National Institute for Communicable Diseases in Johannesburg, South Africa said. He was showing findings of a study finding disparities in HIV care participation in the country that is home to one in six people on earth living with HIV. Of nearly six and a half million people estimated to be living with HIV in South Africa, just a little more than half are linked to care, a little over a third are on antiretroviral treatment, and just a fourth have suppressed viruses, he said. The unlinked people continue to drive new infections, he noted.

On the other hand, an analysis in Rwanda of antiretroviral treatment enrollment indicated that if half the people who need antiretroviral treatment get it and get to stay on it there, new infections will drop by 27 percent each year. That math shows a 46 percent drop in new infections in the second year, a 61 percent drop the third year, and a 71 percent drop by the fourth year. Every 10 percent addition to ongoing antiretroviral enrollment, Dr. Sabin Nsanzimana of Stanford University, Vancouver, Canada said, will bring a corresponding six percent reduction in new infections.

These are more promising results than those yielded by a decade of abstinence-and-faithfulness programs funded by the U.S. President’s Emergency Plan for AIDS Relief at a cost of about $1.3 billion, according to a presentation by Nathan C. Lo, a medical student at Stanford University School of Medicine. His study, which drew on demographic health survey responses in PEPFAR-funded and non-PEPFAR-funded countries, before and after the start of the programs showed no evidence the messaging — to abstain from sex, to delay sexual debuts, to be faithful to one partner — had any effect at all on behavior or HIV risk reduction. The results, he said, indicate a better use for the funding could be found in measures proven to be effective.

The morning also included presentations showing health care costs dropped in correspondence to antiretroviral treatment enrollment, showing people gaining years of live expectancy, and showing hundreds of people in Haiti remaining on treatment for HIV through cholera, earthquake, and civil unrest, all of which tied in to the potential, possibility, and modesty of 90-90-90.

See more on Lo’s study here.

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