ID Week: Making the most of money and science

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SAN DIEGO, CA — Three decades into the AIDS epidemic, quests to identify the most effective responses — in spending, in treatment, and in prevention — continue, but informed by history and advancing science, are coming closer to their target, according to three panelists, in a continuation of ID Week explorations of the shifting HIV landscape.

They spoke at the encompassingly titled “Financing and Global HIV Treatment and Prevention Strategies,” session Friday.

The scope of the President’s Emergency Plan For AIDS Relief is vast with efforts reaching beyond the original “focus” countries, and seeing drops in deaths from all causes in countries where PEPFAR has invested efforts, a notable result in contrast to countries where the response has no presence, began Dr. Charles Holmes, chief medical officer and deputy U.S. Global Aids Coordinator.

But, while by the end of 2011, more than eight million people were on antiretroviral treatment, another 7 million people need it. That unmet need, along with continued growing need —  the numbers of people who should receive treatment is expected only to grow both because of new guidelines and new infections — on top of budget constraints have demanded that PEPFAR develop  a “culture of efficiency,” Holmes said.

It is a response that started in treatment programs and is now spreading to other activities, driven by two themes — expanding the generation and use of economic and financial information, and improving technical and allocative processes. Starting with site level costing studies – looking at what it takes at a site level to fund treatment response — and prioritizing proven impact, “we’re now investing in what works.”

It is an investment, with emphasis on accelerated treatment, medical circumcision, condoms and other evidence-based responses, that could see the number of people newly infected dropping below the number of those needing treatment by 2015, he said.

A reminder of where realities continue to stand in countries confronting the epidemic with few resources came in the next presentation. Graeme Meintjes of the University of  Cape Town said that  in those countries a diagnosis of an opportunistic infection — illnesses controlled by healthy, or treated, immune systems — still carries a high probability of death. Treatment decisions in countries with few resources are further complicated by the advanced illness —  already badly damaged immune systems — with which patients with HIV first come to medical attention. This increases the chance that, on treatment, their recovering immune systems will respond overwhelmingly to the infections they are fighting, resulting in “IRIS”  — Immune Reconstitution Inflammatory Syndrome —  worsening patients’ symptoms. And that in turn shakes patients’ faith that antiretroviral treatment is what they need. All of this has made treating opportunistic infections a delicate balance, with avoiding that sudden inflammatory response competing with the need to control the advance of HIV. Drug interactions, limited available regimens further complicate treatment, he said.

While Meintjes’ talk underscored the urgency of making treatment available before patients’ conditions make the process more complicated and less likely to succeed, the session was rounded out with “glimmers of hope,” from Dr. Myron Cohen who led the HPTN 052 study that proved early treatment will also play a strong role in ending the epidemic.

He began with a reminder — that in response to the AIDS epidemic “in most countries on the planet people did change their behavior and incidence fell,” and  by alluding to a study that, he says will show “better ways to do behavioral interventions,” including mobile testing for HIV. He went on to the promises of vaccine research.

“The field is moving very very fast,” he said. “Most people believe there will be an effective vaccine in  the lifetime of most people in this room.”

In the meantime, in addition to the knowledge that treatment immediately following exposure to HIV, and a steady regimen of medicine before exposure to HIV can prevent infection, we now know that early treatment of people living with HIV will prevent them from transmitting the virus to other people, he noted.

“Thinking you’re going to treat your way out of an epidemic is a big thing to think,” he said. But evidence that early treatment will play a major role in bringing the era of AIDS to a close continues to mount, he added. He pointed to “a very nice study” in South Africa, showing that newly infected people — people who have had no time to learn of or address their infection — play less of a role in the spread of HIV than previously thought, indicating that immediate treatment for people known to be infected can effectively turn off the main source of transmission.

“Now,” he concluded, “is the time to redouble efforts.”


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