Leading up to World AIDS Day, there have been rallying calls to scale up HIV prevention and treatment services around the world. When it comes to treatment as prevention, there is little doubt that the HIV Prevention Trials Network (HPTN) 052 study has played an important role in furthering our understanding of the benefits of this strategy. HPTN 052 was the first randomized clinical trial to show that providing early antiretroviral therapy (ART) to an HIV infected person can reduce the risk of sexual transmission of HIV to an uninfected partner by 96 percent. In addition to evaluation of the prevention benefits of ART, the study was also able to demonstrate the impact of early ART on clinical outcomes of the HIV-infected partners. Those HIV-infected partners in the early treatment arm had a 41 percent lower risk of clinical events compared with those for whom treatment was delayed.
HPTN 052 has been called a “game changer.” In her speech, “Creating an AIDS-Free Generation,” U.S. Secretary of State Hillary Clinton referred to the HPTN 052 study and the impact it has had on the fight against AIDS. She recommended that the fight include combination prevention strategies, such as expanding voluntary medical male circumcision and scaling up treatment for people living with HIV/AIDS. “For years, some have feared that scaling up treatment would detract from prevention efforts,” said Secretary Clinton. “Now we know beyond a doubt if we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to prevention. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention.”
Findings from HPTN 052 have also prompted policy recommendations from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Some of these include:
- Expand HIV counseling and testing through PEPFAR, including health facility‐based, community‐based, and home‐based testing. Expand access to HIV testing and counseling for couples in all of these venues.
- Scale up HIV treatment to reflect a higher proportion of the PEPFAR budget, perhaps as much as 50 percent.
- Evaluate all PEPFAR prevention expenditures based on scientific evidence of their efficacy. Shift resources from less efficacious interventions to those with documented efficacy in reducing HIV incidence, including ART.
- Include HIV treatment as a key prevention intervention in all demonstration projects or evaluation studies of combination prevention strategies.
- Work urgently to provide country guidance encouraging the strategic use of treatment as prevention throughout PEPFAR programs. This includes integration of HIV treatment as a key component of combination prevention efforts that might include expanded medical male circumcision and other evidence‐based behavioral, biomedical and structural prevention interventions.
As we take a moment to reflect on the 30th anniversary of the AIDS epidemic, World AIDS Day gives us an opportunity to appreciate the progress that has been made but also recognize the challenges we continue to face. It also reinforces the need to renew our commitment to develop, evaluate and implement effective prevention strategies and combination approaches that can help reduce the number of people who become infected with HIV and to improve the health outcomes of those living with the disease.