SAN DIEGO, Calif. – After the HPTN 052 trial settled the question of whether early HIV treatment prevents transmission of the virus, the START trial settled the question of the value of treatment for individual health, Dr. Myron Cohen noted during a talk Thursday.
That leaves two big questions in the wake of the World Health Organization release of updated HIV treatment guidelines, recommending all people infected with HIV receive antiretroviral therapy without delay, he said. One centers on the logistics of delivering antiretroviral therapy to all 37 million people living with the virus, he said, the other on how to reach people during acute HIV infection, which occurs shortly after acquisition of the virus.
Treating people within the first few weeks of infection ensures that immune cell — or CD4 — counts remain high and viral load remains low, Cohen said. Treating early after infection not only improves health outcomes for individuals, limiting reservoirs of the virus, but lowers risk of transmission at a critical point. For this reason, Cohen said, public health efforts in his home state of North Carolina are focusing on “cluster busting”, or targeting networks of people at high risk for HIV infection, including men who have sex with men, with early antiretroviral therapy.
Some individuals, Cohen said, can even go without antiretrovirals for long periods of time if treated very early.
The question now is, “how much damage are we doing by missing acute infection, a little or a lot,” Cohen said.
HIs talk came during a session on HIV prevention, which also featured an update on topical microbicides to protect against acquisition of the virus.
It is a measure that needs an image makeover, said Jeanne Marrazzo of the University of Washington. That makeover, she said, might include a better name than “microbicides.”
She noted that clinical trials have shown low adherence and limited marketability and uptake of microbicides combined with the proven impact of treating infected people on preventing transmission have raised questions about the value of microbicides.
But with one third of new infections globally occurring among young women in sub-Saharan Africa, Marrazzo said, microbicides will be necessary to provide on-demand and possibly multipurpose protection – combining contraception with protection against HIV – for women.
“The first microbicides had good intentions but bad results,” she said. The early days of microbicide development “hurt the field” Marrazzo said, because those early products, which didn’t contain antiretrovirals, were ineffective. Now, along with developing effective microbicides, researchers need to figure out why, in trials including the VOICE study — of Vaginal and Oral Interventions to Control the Epidemic — women said they were using products when they weren’t, Marrazzo said.
The answer to low uptake might lie in sustained delivery products, including a vaginal ring, Marrazzo said. The results of the ASPIRE vaginal ring study are due out early next year.