In the sixth in a series of debates hosted by the World Bank and the U.S Agency for International Development highlighting emerging issues in today’s HIV response, physician-scientists debated how best to transform the exciting results from the HIV Prevention Trials Network (HPTN) 052 study, which demonstrated that those with HIV infection who received immediate treatment with antiretroviral therapy (ART) were 96 percent less likely to transmit HIV to their uninfected sexual partners than those whose treatment was delayed.
The panelists were tasked with debating not only how to apply treatment as prevention (TasP) quickly, and how to add it to the combination prevention tool kit effectively, but more so whether or not it makes sense to have countries spend a majority of what is likely to be a flat or declining HIV prevention budget on TasP. Each panelist was assigned a pro or con stance.
Arguing “for,” Sten Vermund, MD, PhD, said that if there were a vast pool from which to spend, there would be no debate. The evidence is overwhelming of the efficacy of ART as prevention, and a lack of scientific evidence in other prevention areas. He also said that priority must be given to reaching those folks with a CD4 count less than 350.
After noting how “clever” it was to ask him to argue against the results of his own study, Myron Cohen, MD, principal investigator of the HPTN 052 trial, retorted, “Why would we ask every program in the world to shift resources?” The HIV epidemic includes men who have sex with men and injection drug users – we don’t yet know if these key populations will see the same prevention benefit from increased antiretroviral (ARV) use, and investigators at this point are reporting conflicting observational data in these populations, he said. Cohen added that they don’t yet know the duration of this treatment benefit and that they need more research to assess the durability, adherence, resistance and infrastructural support. “It’s not ready for prime time,” he said.
Wafaa El-Sadr, MD, MPH, said she was surprised at the timidity of her opponents given that HPTN 052 has shown the highest level of protection to be derived from a prevention intervention. We can even use existing treatment set-ups to catapult service expansion, she said. “We have the tools, knowledge, platform and people to make this happen right now,” but we need to have high yield in our testing campaigns and stop testing those who repeatedly test negative. One great pool for testing, she said, was to bring in the partners of those receiving ARVs through PEPFAR – fifty percent of whom are in discordant relationships.
Stef Bertozzi, MD, of The Bill & Melinda Gates Foundation, agreed with Cohen, saying that applying any rigid rule – such as X percent of prevention dollars must be spent on TasP across all PEPFAR countries – would be a mistake. “In a very heterogeneous epidemic, it doesn’t make sense… but should be decided on an individual, per- country basis.” Bertozzi also called his co-panelists to task in identifying line items to stop funding in order to scale up TasP, to which Vermund responded we have an immediate opportunity to transfer funds from prevention strategies that do not have evidence to support them. For instance, he said, we do not have the evidence that behavior change works, to include abstinence only education programs and often poorly constructed mass media campaigns. Vermund said that there is also money being spent on female condoms with little evidence of their utilization and overall benefit.