Two new studies (one in Kenya and Uganda, the other in Botswana) were published this week suggesting that administering HIV antiretroviral (ARV) drugs to the general population could reduce the risks of HIV transmission by 60-70%.
In May we reported on a study that showed this worked for reducing infection rates between sero-dsicordant couples (i.e. where one is HIV+ and the other is uninfected). These newer studies however, suggest that making ARVs available to the general population in communities where there is a high incidence of HIV infection could dramatically reduce the rate of infection overall.
There are big questions about the reality of turning this into a realistic and ethical prevention strategy. Firstly, it does not always work – an earlier study (FEM-PrEP) using the same drug as the Botswanan study (Truvada) showed no impact. The reasons for that disparity are unclear, but may have to do with adherence – i.e. the benefits disappear if the drugs are not taken consistently.
Secondly, there is the cost – ARVs are still not cheap, and making them available to uninfected people when the majority of those with an AIDS diagnosis worldwide cannot get access to them raises real questions about affordability and the ethics of how aid money is distributed. In other words, given limited funding, do you invest in helping those who are already ill, or in stopping some of those who might get ill from becoming infected?
Thirdly, is it ethical to make available drugs (with all their side effects) to otherwise healthy people? Especially if, in doing so there is a risk that we could undermine other proven strategies such as partner reduction (so called ‘zero grazing’), abstinence and condom usage?
Using HIV antiretroviral therapy as a prevention strategy is rapidly gaining a body of supporting evidence. This is good news, as the argument for getting more people on to ARVs worldwide is boosted – it not only saves the lives of the infected, but reduces the rate of new infections. This gives added weight to efforts to get 15 million people living with AIDS on to ARV by 2015.
At the same time, if this happens at the cost of the massive gains in more comprehensive prevention strategies, we could find ourselves back peddling on the progress made in prevention initiatives over the last two decades. These initiatives have shown that not only behaviour change and treatment are important, but community engagement and awareness, government commitment and a partnership with civil society, including the churches, is vital.
Let us hope that the global community proceeds wisely with its growing tool box to tackle the HIV & AIDS pandemic, and does not forget the hard learned lessons of the last three decades.