Test and Treat was one of the few sessions I was ‘kind of able’ to follow at the latest British HIV Association (BHIVA) conference in London at the beginning of the month. In spite of all my ‘activism’ when I listen to very scientific presentations my brain switches off and most of the information passes over my head.
Anyway here is a very simplified version.
In the past few years it has become clear that an undetectable viral load does reduce infectiousness immensely. This is why, for example, preventing mother to child transmission is so successful once women have an undetectable viral load. And this is also why the Swiss Doctors released the controversial ‘Swiss Statement’ giving the green light to unprotected sex to monogamous, heterosexual, sero-discordant couples on effective treatment.
This topic is crucial to the world of public health not because the grey suits really want us who live with HIV to have guiltless and condomless sex, or ‘Nyama Kwa Nyama’, doing it flesh to flesh, as my Swahili speaking friends say with starry eyes. What really matters to policy makers is finding a shortcut to prevention. World Health Organisation (WHO) believes that if with undetectable viral load you can stop sexual transmission of HIV we can treat our way out of the epidemic. All it is needed is: testing everybody on the planet every year (!) and putting them on ARVs straight away, regardless of CD4 count, for the rest of their life.
Professor Myron Cohen, from the University of North Carolina, who opened the session, highlighted three major concerns clouding the picture:
- Transmission of resistant viral strains
- The contribution of patients with acute and early HIV (subjects who are not likely to be detected routinely but contribute substantially to the spread of HIV)
- The practicality of the idea.
Prof Myron also gave us the example of a recent study in China among 1927 sero-discordant couples on treatment. This study reported around 4% transmission among couples where the HIV positive partner was on ARVs. This study was not considered conclusive because they didn’t use viral load monitoring. However it provides a real life example of some of the problems of ‘Test and Treat’.
The second presentation of the session, by Dr Steve Taylor from University of Birmingham, looked more in-depth to the scientific side of preventing HIV transmission. In order to reduce sexual HIV transmission it is crucial to understand better how HIV works once it is inside the body. Some drugs can penetrate the genital tract and stay there at a good level, thus protecting us from passing the virus. But not all the drugs work the same way and the collection of samples of genital fluids for research has its challenges!
What I find really exciting is that the criteria of reducing sexual infectiousness will be paramount in developing new drugs and better combining the drugs we already have. Personally I was really relieved and felt immediately less infectious just by knowing that the drugs I am using score really well in the genital tract!
A poster presentation by Dr Taylor and the team he works with, including more information on how different drugs penetrate the genital tract is available here.
As a person with HIV I am definitely very excited at the idea that one day I may not be considered a viral threat to the world. I think that if sexual infectiousness could really be eradicated this would play an important role in decreasing stigma.
However, I think there are several problems with the ‘Test and Treat’ approach. Firstly an ethical one: is it right to give somebody potentially toxic treatment in the name of prevention? And could this lead to human right abuses in which vulnerable and stigmatized populations, such as sex workers and drug users are forced to be tested by the police?
Secondly an economic and political one: in a time in which we can not even test and offer treatment to millions of people who are dying of AIDS around the world, because of lack of money and political will, discussing the ‘Test and Treat’ model seems a purely academic exercise.