HIV This Week

Steinbrook R. Message from Toronto--deliver AIDS treatment and prevention. N Engl J Med 2006;355:1081-4. http://content.nejm.org/cgi/content/full/355/11/1081

In this perspective article, Robert Steinbrook looked back on the Toronto AIDS conference arguing that the growth of the pandemic continues to outpace the broad and expanding efforts to control it. Since HAART became available a decade ago, the treatment of HIV infection has been streamlined — for example, from 10 pills daily taken in three doses with food restrictions to as little as 1 pill once a day. Many presentations at the conference showed that treating HIV is feasible in all countries. The best price for a first-line regimen of generic antiretroviral drugs in low-income countries is now about US$130 a year for adults (down from US$285 in April 2004) and less than US$200 a year for children. In 2005, there were an estimated 4.1 million people newly infected with HIV and 2.8 million AIDS-related deaths. The author reviews resource needs and estimates of actual funding, coverage of specific prevention programmes, and includes a chart which compares coverage of antiretroviral treatment by country. Countries with less than 35% of those in need on treatment include Trinidad and Tobago, Burkina Faso, Zambia, Chad, Benin, Cameroon, South Africa, Kenya, Burundi, China, Malawi, and Ethiopia. He then summarises biomedical approaches to prevention currently being evaluated, often in large controlled trials. These include cervical barriers, such as the diaphragm; therapy to suppress herpes simplex virus type 2, the primary cause of genital herpes (a risk factor for acquiring and transmitting HIV); microbicides that could be applied to the vagina or rectum; male circumcision; pre-exposure prophylaxis with antiretroviral drugs; and expanded treatment of infected persons not only for their own health but also to prevent HIV transmission. He then highlights the consensus view that providing antiretroviral therapy to subjects who acquire HIV infection during the course of a study is an indispensable part of the agreement between trial sponsors and trial participants. He suggests that there is disagreement, however, about the obligation to people whose infection is detected when they are screened for trial eligibility, as well as about who should assume the long-term financial costs and manage the complexity of treatment – trial sponsors, the country where the trial is conducted, an international fund, or someone else. Although trial participants are unlikely to need treatment until years after they become infected, they will eventually need it for life.

Editors’ note: UNAIDS is following up on the recommendations of an international consultation on creating effective partnerships for HIV prevention trials in 2005. The whole process, which included three regional consultations, was initiated as a result of the suspension of the tenofovir trials in Cambodia and Cameroon. We are planning three meetings over the coming months to address three specific recommendations: to develop Good Community Practice Guidelines which outline processes, procedures, and minimum requirements for community engagement in HIV prevention research; to identify programmatic and financing approaches for providing care and treatment to people who develop intercurrent infections (or who are screened out at recruitment for HIV prevention trials because they are found to be HIV-positive); and to revise and update the 2000 UNAIDS guidance document on ethical considerations in HIV preventive vaccine research (to be expanded to apply to all HIV prevention trials).