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Ugandan ART study foreshadowed HPTN 052
[Editor's note: The recent HPTN 052 study that showed such dramatic success from antiretroviral therapy (ART) being given early to help prevent HIV transmission among HIV discordant couples followed on the footsteps of early research that suggested such a trend. One such study was conducted in Uganda between 2003 and 2007. It followed ART-naïve, HIV-infected adults in an AIDS program that provided many standard prevention interventions, including annual counseling and testing for cohabiting partners, risk reduction plans, condom distribution, and prevention support. The HIV-infected partners were started on ART. The study found that despite a reported increase in sexual activity that was 41% at 36 months, consistent condom use was high with discordant partners, and estimated HIV transmission risk was reduced 91%.1 AIDS Alert asked two investigators with the Ugandan study to discuss their research findings, particularly in light of the recent announcement that HPTN 052 was halted early so all study participants could be offered early ART. Rebecca Bunnell, ScD, MED, associate director for public health practice at the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, and Jonathan Mermin, MD, MPH, director of the division of HIV/AIDS prevention at the CDC, answered a few questions about their study and its implications in this email question-and-answer (Q&A) exchange.]
AIDS Alert: What was the chief finding of your study on Ugandans with HIV and antiretroviral therapy?
Bunnell & Mermin: Providing antiretroviral therapy and sexual behavior education through a home-based care program was associated with a 91% reduction in estimated HIV transmission risk even though the median HIV viral load at baseline was high, at 122,500 copies/ml. The reduced risk occurred even in a challenging rural African setting where the average per capita daily income was less than $1, there was no access to electricity or running water, and three-quarters of people had not had education beyond primary school.
AIDS Alert: What are the implications of these findings, especially in light of the recent good news that ART significantly reduces the risk of HIV transmission?
Bunnell & Mermin: These results are consistent with the recent findings of a randomized trial among people with relatively high CD4 cell counts, a measure of immune function. In our study, people with HIV had advanced disease, with CD4 cell counts below 250 cells/uL and high viral loads, suggesting a high chance of transmission. Together, the two studies support efforts to increase access to antiretroviral therapy and sexual behavior education to all people with HIV, and highlight the synergistic effects of prevention and care.
AIDS Alert: The CDC has focused on HIV screening and referral to care for some time now. Do you think the findings, such as those in your study and the HPTN -052 study, will lead to public health policy and guidance changes? Why or why not?
Bunnell & Mermin: In the United States and internationally with Ministries of Health, CDC has highlighted the importance of HIV screening and linkage to careboth for the life-prolonging effects of antiretroviral therapy and care and for the prevention benefits, yet in most countries in Africa less than 25% of people with HIV know they have the virus. In the United States, the Department of Health and Human Services therapy guidelines already support offering antiretroviral therapy to people with CD4 cell counts below 500 cells/uL and are permissive for all people with HIV regardless of CD4 cell count with consideration of particular circumstances, such as being in an HIV-discordant couple. The findings of these new studies and previous research support a flexible approach, and may have implications for many countries that are currently balancing a tremendous need for HIV-related care, restricted health sector budgets, and a realization that providing antiretroviral therapy to more people with HIV, even with higher CD4 cell counts than currently indicated by some Ministries of Health and the World Health Organization, will help people live longer, healthier lives and reduce the number of new HIV infections. The difficult choice presented here is a classic public health conundrum: potential benefits to individuals and society are clear, but resources are limited. Will we make an explicit choice, and if so, what scientific, ethical, and economic factors will be incorporated into our decision-making?