Treatment 2.0: Aspirations for Invigorating the Global HIV/AIDS Response

Two weeks ago, the United Nations Joint Programme on HIV/AIDS (UNAIDS) released Treatment 2.0, the latest global strategy for making HIV treatment more efficient, accessible, and effective. Although refreshing in its emphasis on alternative or newer methods to approach HIV treatment and prevention, the strategy document stops short of offering practical guidance on how to act or fund its five key recommendations for invigorating the global HIV/AIDS response:

i) Recognize and use HIV treatment as a tool for preventing new infections

ii) Develop better combination antiretroviral medications and cheaper diagnostics tools

iii) Find ways to lower other HIV-related costs

iv) Expand the availability of HIV testing and build stronger links between HIV testing and care

v) Encourage and support community leadership in expanding and improving local HIV responses.   

UNAIDS suggests if countries can provide antiretroviral therapy (ART) to all people living with HIV who need treatment, the Treatment 2.0 strategy could prevent up to one million new HIV infections each year and as many as 10 million AIDS-related deaths by 2025.

Treatment is prevention
Treatment 2.0 is one of the first formal documents to recognize and recommend ART as a prevention tool.  In part, the guidelines reflect the now substantial data, which show that the risk of HIV transmission is greater when a person’s viral load is higher. This data provides a compelling argument for putting a person living with HIV on ART both to improve the individual’s health and to lower the risk of transmitting HIV to sexual partners. [1] More compelling data on whether ART can prevent heterosexual transmission from an infected individual to their discordant partner will come from the ongoing HPTN052 randomized clinic trial.  In this study, people living with HIV are randomly assigned to a group that receives either immediate or delayed ART based on their clinical histories and CD4 count. The frequency of HIV transmission between partners will then be compared between the groups. Of course, the broadest ART coverage would require putting all people living with HIV on treatment regardless of CD4 count as proposed in a recent “Test and Treat strategy” reviewed by the World Health Organization . [2] This strategy is particularly contentious given the current economic outlook. Instead, the Treatment 2.0 strategy proposes a less ambitious plan of starting treatment when CD4 counts drop below 350 cells/mm³, which means people would still be started on treatment earlier than in the past when a CD4 threshold of 250 cells/mm³ was standard. This ‘new’ strategy to start treatment earlier is based on considerable data, also reflected in the recently revised DHHS guidelines in the United States. [3] The ongoing HPTN052 trial will also offer additional evidence of the individual clinical benefits of starting ART at CD4 counts between 350-550 cells/mm³. The trial’s initial results are expected in 2012.

[Click here to read more about the other four pillars of Treatment 2.0]

—Cindy Gay, MD, HIV/AIDS Clinical Advisor

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Posted by Cindy Gay at 01:30 PM