27 Nov 2008

GNP+ supports WHO recognition of Treatment as Prevention

The Global Network of People living with HIV (GNP+) welcomes the assertion from WHO that widespread access to HIV treatment contributes to prevention (a) – but concerns need to be addressed.

GNP+ welcomes the WHO breakthrough in thinking on Treatment as Prevention

Treatment as Prevention is a concept that has been known and lived by people living with HIV (PLHIV) for some time. GNP+ in collaboration with the South African Human Sciences Research Council (HSRC) recently finalised a WHO-funded research project(b) in which 51 serodiscordant couples in three countries (South Africa, Tanzania and Ukraine) were interviewed (c), including the role of treatment in their relationships and reproductive choices.

The hypothesis put forward by the WHO mathematical model asserts that universal annual voluntary HIV testing and immediate treatment with ARVs – regardless of CD4 status – could eventually drive the HIV epidemic towards elimination. This assertion is based on an acceptance of the idea that HIV transmission decreases when PLHIV are on treatment.

This is a breakthrough in thinking from the UN agency. GNP+ appreciates that the model indicates clearly that universal voluntary testing and early treatment lead to a significant reduction in HIV transmission.

The positive aspects of this model are that it assumes that testing will become more widely available and that treatment access will improve to the point where everyone who tests HIV positive will have access to ARVs when they choose to commence treatment.

Concerns remain to be addressed

However, from the point of view of PLHIV several concerns remain to be addressed:

(1)    The concept of annual voluntary testing needs to be thought out clearly to ensure that testing actually remains voluntary. HIV testing should never be mandatory.

(2)    Treatment commencement must remain the individual choice of the person living with HIV because it involves considerable long-term toxicities – especially when started early – as well as a serious long-term commitment to treatment adherence. As with all chronic diseases, the choice to begin treatment must be based on the best advice of the health care provider but the ultimate decision lies with the patient.(d)

(3)    Feasibility: given the inability of governments to live up to their commitments with respect to universal access for PLHIV who meet requirements for treatment, it is difficult to imagine a situation where governments will be willing and able to address universal access for all who test HIV positive, regardless of their CD4 status.

(4)    Criminalisation: given that current legislation in some cases criminalises the mere exposure to HIV, will the increase in testing lead to more criminalisation of PLHIV? Increased testing efforts must be balanced with the concerns of PLHIV not to be criminalised.

In spite of these concerns, GNP+ fundamentally welcomes WHO’s recognition that treatment reduces the transmission of HIV.

Proposed way forward

As a way forward GNP+ calls for WHO to work closely with communities and especially PLHIV networks to develop policies and programmes designed to increase access to testing services and ARVs for PLHIV. At the same time, PLHIV human rights need to be safeguarded, including the right to choose when to get tested and when to start treatment.

NOTES:

(a) Granich R et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. The Lancet (online publication, November 26 2008): doi:10.1016/S0140-6736(08)61697-9; De Cock K et al. Can antiretroviral therapy eliminate HIV transmission? The Lancet (online publication, November 26 2008): doi:10.1016/S0140-6736(08)61732-8.

(b) Research results are forthcoming shortly.

(c) Some of the preliminary findings underscore the reproductive desires and preoccupations PLHIV and serodiscordant couples have as this example of a HIV positive woman from a South African couple demonstrates: “I do have love for children and I still want to have one, but I am scared to infect my partner? that’s the only challenge that I have.”

(d) See Garnett G, Baggeley RF. Treating our way out of the HIV pandemic: could we, would we, should we? The Lancet (online publication, November 26 2008): doi: 10.1016/S0140-6736(08)61698-0.

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