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AIDS Alert International: Will better HIV treatment mean higher STD rates?
Acute infection studies offer prevention window
Antiretroviral treatment soon will be available to millions more people in sub-Saharan Africa and other developing nations, and international HIV experts fear they’ll see increased risk behaviors when the drugs become commonplace.
In anticipation of this, the Global HIV Prevention Working Group issued a report in June 2004, calling for an expansion of prevention programs and greater integration with existing treatment programs.
The HIV Prevention in the Era of Expanded Treatment Access report claims this is a unique opportunity to build a comprehensive approach to treatment and prevention in nations that have struggled with both facets of HIV intervention.
"We want to highlight that there is concern that risk behavior could increase, and we could see an increase in sexually transmitted diseases (STDs) and HIV as we’ve seen in some Western, developed nations where treatment access has existed for longer periods of time," says Helene Gayle, MD, MPH, of the Bill & Melinda Gates Foundation.
She adds that it’s hard to say that has happened elsewhere due to a complacency or from a shift in resources.
"But it’s clear if we look at the experience of the United States and United Kingdom and others, we’re seeing disturbing trends in risk behaviors and increases in HIV and STDs," Gayle notes
For example, in Australia, the rate of new HIV infection has increased 22% over the last five to eight years since the full access to treatment has been available, she says.
Meantime, U.S. investigators and others are studying ways to identify people who recently were infected with HIV and still are in the acute infection stage.
"We think it’s of great public health benefit to identify acute infections," says Myron Cohen, MD, a J. Herbert Bates Distinguished Professor of medicine, microbiology, and immunology and director of the division of infectious diseases and the director of the Center for Infectious Diseases at the University of North Carolina at Chapel Hill.
Cohen and other researchers have developed a cost-effective way to identify acute HIV infection through a pooling process that tests the blood of individuals who tested negative for HIV on the antibody test. This process, using the HIV RNA, identifies those individuals who are acutely infected.
For example, in one sub-Saharan African clinic, researchers tested 1,300 blood samples and found that 2% of patients had acute HIV infection, says Cohen.
"If two out of 100 people have an acute infection then they’re many times more infectious than others," he notes. "So finding those two people is very important."
Researchers have no doubt that the magnitude of viral burden in the first weeks of HIV infection present a major transmission risk, he says. "In addition, many of these people have untreated sexually transmitted diseases (STDs) at the same time."
So a future prevention strategy will be to identify people who are acutely infected with HIV, provide them with prevention information, and ultimately, treat them with a therapeutic intervention designed for acutely infected individuals, Cohen says. "We’re in the infancy of developing strategies."
Meantime, there are plenty of prevention strategies that could easily be adapted to work with HIV treatment programs, the global HIV experts say.
For instance, Brazil has had success with integrating prevention and treatment services, says Paulo Teixeira, MD, MPH, former director of Brazil’s national AIDS program and currently with the World Health Organization in Geneva.
"If you have a comprehensive approach, it’s easier to mobilize and involve people and their friends," he says.
"People will feel we are offering something that offers hope to infected people, and this is fundamental to having these people as a partner of the health structure and of our project," Teixeira says.
A national survey of homosexuals and observed behavior in Brazil in 2002 showed that rates of condom use and adoption of safer sex behaviors did not decrease as a consequence of greater access to treatment, he points outs.
So this indicates that when prevention and treatment are integrated, it is possible to prevent the problems Australia, the United States, and the United Kingdom are having with increases in risk behavior and HIV infection, he adds.
"Secondly, the promotion of treatment will have a very important role in prevention, particularly, because you will promote more complete HIV testing," Teixeira says.
The challenge will be for governments to continue and improve prevention funding at the same time additional resources are going toward treatment, Gayle notes.
"The case for treatment is always obvious and more compelling than the case for prevention," she says. "The ability to see people get sick and become better is more tangible and obvious; we spend much more resources on treatment than we do for prevention."
The other issue is that when a government scales up treatment, there’s a tendency to make a financial trade-off when it comes to prevention resources, Gayle explains.
"In 2002, there was $2 billion spent on prevention, and by 2005, we need $5.7 billion, so that means there’s a gap of $3.8 billion," she says.
However, with the HIV epidemic, any funding cuts in prevention programs eventually will cost more in treatment, Gayle points out.
"We need to remember that people who are HIV-infected also need prevention services," she says. "Prevention services need to be geared to keep people from acquiring it and to keep people who have the potential to continue transmitting HIV to remember prevention as well as their treatment needs."