Blueprint: Dr. Myron Cohen on treatment as prevention and other essential elements of a global AIDS plan

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Dr. Myron S. Cohen is the architect and principal investigator of the multinational HPTN 052 trial, which demonstrated that antiretroviral treatment prevents the sexual transmission of HIV-1. This work was recognized by Science Magazine as the “Breakthrough of the Year” in 2011. His research focuses on the transmission and prevention of transmission of HIV, and much of his research has been conducted in resource-constrained countries. He is the J. Herbert Bate Distinguished Professor of Medicine, Microbiology and Immunology and Public Health at the University of North Carolina at Chapel Hill.  He serves as the Director of the UNC Division of Infectious Disease and the UNC Institute for Global Health and Infectious Disease, and Associate Vice Chancellor for Global Health, as well as co-principal investigator of the National Institutes of Health HIV Prevention Trials Network (HPTN).

He answered these questions for Science Speaks’ Blueprint series.

In her address to the International AIDS Conference in July, Secretary Hillary Clinton called for the U.S. Office of the Global AIDS Coordinator  to create a blueprint — a plan for what the U.S. would contribute reach the goal of an AIDS-free generation — to be released by World AIDS Day in December. From your perspective as a scientist and clinician, what key elements should be a part of this blueprint?

In the past year the Obama administration—spearheaded by Secretary Clinton— has been very clear about their commitment to fighting HIV worldwide.  Their strategy embraces a strong focus on treating more people and preventing more cases of infection. I think the blueprint will inevitably focus on these issues and will emphasize marginalized and hard-to-reach populations that continue to suffer, and also fuel parts of the epidemic.

When policy makers talk about a combination prevention package, what interventions would you highlight as critical components of combination prevention?

Circumcision clearly reduces HIV acquisition. And I think safer sex counseling and condom use has reduced HIV incidence worldwide, although not nearly enough. Treating sexually transmitted infections is always a good idea. But the cornerstone of combination prevention, resulting from many years of research, is expansion of treatment.   HIV-infected pregnant women who are virally suppressed very rarely transmit HIV to their babies, and HIV-infected adults who are virally suppressed are also far less likely to transmit HIV to an uninfected partner. And there is also data to show that early treatment preserves the health of an HIV-infected person. I anticipate that other components, perhaps especially PrEP and microbicides, will play specific and important roles.

Based on the latest research, what should global programs like PEPFAR be aiming for in terms of timing to initiate treatment in HIV-positive people?

Current evidence has led all US HIV guidelines to recommend treatment of HIV regardless of CD4 count.  Global programs will focus on the WHO normative guidelines, and new WHO guidelines are now being developed.  Such guidelines—which are evidence based—are certain to recognize the importance of earlier treatment of HIV infection, while offering a view of priorities in the face of limited resources or infrastructure.

Should OGAC and the blueprint put forth a prioritization process for use of U.S. tax dollars?

Any blueprint will try to get the most “bang for the buck,” which translates into a plan that best improves global health and prevents the most cases of HIV. OGAC will surely use modeling exercises to examine different strategies.

What should the priorities be?  Are there elements of the current program that should be abandoned in favor of these priorities? If so, which ones?

Certainly there is a controversy about investment in different programs, including the expansion of treatment.  But this discussion includes two important realities:34,000,000 people with HIV need treatment now or soon, and the US, in partnership with the Global Fund and other donors, has been a visible and constant leader in this regard.  This commitment is not going away.  And the “treatment mortgage” –commitment to treating so many people— is actually a “variable interest loan”.  Treatment will inevitably evolve to greater efficiency, lower cost and development of new strategies we have not yet envisioned.  People need to think how far we have come since 1980 in the treatment of HIV infection.  We need a little wishful thinking as we go forward and expand the number of people treated.

What role should research play in the blueprint?  If you believe it should play a role, what research questions should be prioritized?

We need to make an HIV vaccine and find a cure for AIDS.  But these goals are not meant to diminish what we can accomplish now.  Everything we do today serves as a bridge to an “AIDS free Generation”. HIV prevention research must focus on development of ever better prevention tools, and ever better strategies to implement these tools.

Assuming the blueprint lays out a 5-year plan, what are some examples of targets and outcomes that you think should be included?

We need to be clear about what happens if you get a test: IF YOU TEST POSITIVE, YOU OUGHT TO GET TREATED.  We have inadvertently created mass confusion about “when to start” ART, through many, many changes in treatment guidelines, and because of different guidelines in different countries.  People who get treated will be retained in care better than those told to return at a later date. I anticipate that the big combination intervention studies (e.g. HPTN 071, CDC-Botswana, USAID Iringa-Tanzania, ANRS KZN)-which focus on immediate treatment as part of a combination package- will show that HIV prevention works.

How can this blueprint address previous failures to reach affected populations with prevention, testing, and treatment?

Can we find and engage “hard to reach” populations (having accepted they are hard to reach). This is a challenge that has not been fully addressed.

Should a blueprint set goals that certain to be attained, or aspirational goals that would be ideal – i.e. every infected person on treatment – with the risk of falling short?

We NEED aspirational goals, but we must also be candid about what needs to be done.  Everyone with HIV needs treatment; the more we defer ART, the more new cases there will be (since treatment prevents transmission), and HIV becomes more difficult to treat (because with the current strategy people present late to care).  Timing the inception of treatment to CD4 count is difficult and so all too often people present with very low CD4 count, or AIDS.  Late presentation with HIV is an unnecessary tragedy.


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