In 2009, a team of World Health Organisation (WHO) scientists published a study in the British medical journal The Lancet claiming the HIV pandemic could be brought to an end within 10 years, with universal annual HIV testing followed immediately by treatment for patients who test positive, regardless of the state of their immune system.
Dubbed the "test and treat" approach, it has been hailed as an historical opportunity to eradicate HIV from the surface of the planet, and was a highlight of the 2010 International AIDS Conference which took place in Vienna in July. It also figured on the agenda of the Australasian HIV/AIDS Conference which took place last week in Sydney.
But Professor Susan Kippax from the Social Policy Research Centre at the University of NSW says the study’s mathematical modelling is unrealistic. Kippax is blunt: "WHO is misguided," she told New Matilda.
The study is based on evidence observed among heterosexual couples in which one partner is HIV positive and the other is not that HIV antiretroviral therapy (ART) reduces patients’ viral load, thus lowering the likelihood of HIV transmission. It recommends annual universal voluntary testing of all people over the age of 15; the authors argue that in the long-term this approach is the most cost-effective way to combat the spread of the virus.
Kippax terms the strategy a "silver bullet" and says she is concerned about the increasing dominance of biomedical prevention in public health at the expense of political and behavioural change. She argues that all biomedical prevention tools, be they condoms or clean needles, require behaviour change and the right context in order to be effective. In other words, the drugs aren’t enough.
Australia cottoned on to this early with one of the most innovative and successful HIV responses in the world. Since the mid-80s, federal and state governments have worked on a bottom-up approach with community organisations, mixing biomedical prevention and social change.
Law reform, such as the decriminalisation of homosexuality in NSW in 1984 and the controversial introduction of needle exchange programmes played a crucial role in averting a serious epidemic. But Kippax says the new focus on biomedical interventions will give governments "a beautiful reason for not having to address sex and drugs".
And while Assistant Director of the National Association of People living with HIV/AIDS (NAPWA) Sean Slavin says Australian activists, scientists and government representatives work in a cooperative fashion, he is also worried by a tendency "to always race towards the medical intervention". His concern is that, even in NSW, the "treatment as prevention" debate can edge toward a public health approach that puts the welfare of individual patients second to the benefit of the general population.
To start a patient on ART is to make a considerable commitment, says Slavin. "It means taking medication everyday for another 40 or 50 years, and the side-effects are often people’s first experience of illness in relation to HIV." Pressuring patients to start early may also mean poor adherence to the treatment regimen, which risks producing a resistant strain of the virus — "both a problem for the individual and the community," says Slavin.
For now, the lead author of the paper in The Lancet, WHO HIV/TB Medical Officer Dr Reuben Granich, says WHO’s only focus is on increasing testing and counselling worldwide and ensuring that all people whose immune system is failing have access to treatment. In fact, WHO avoids using the term "test and treat", as it has become associated with testing everybody and treating them immediately, which angers human rights activists, Granich told New Matilda.
He is adamant WHO would never recommend a mandatory or coercive approach, but he doesn’t think "anyone would argue that it is a bad thing for people to know their status, so they can access ART to save their lives."
Here Kippax raises some concerns. She told New Matilda that "many people resist being tested in the developing world, since they are terrified of finding out if they are HIV positive because of stigma."
In PNG, Maura Elaripe, founder of Igat Hope, the umbrella NGO for people living with HIV, was forcefully sterilised because of her HIV positive status. In a country with high levels of gender-based violence, Elaripe says it is "very hard for women to come home after a routine test and tell their partner they tested positive."
Doctors recently told Elaripe they are no longer registering new patients on ART because they are worried PNG might run out of treatment supplies. For them, the risk of a patient developing drug resistance while on a treatment break is too dangerous. The Global Fund to Fight AIDS, Tuberculosis and Malaria last year rejected PNG’s application for HIV funding based on its stringent accountability criteria. It will provide another two years worth of ART for PNG’s 6500 patients currently receiving treatment — but not for new cases. PNG’s government has however stepped in with a promise of 6 million kina (AU$ 2.3M) for medicines and has applied to the next round of Global Fund money.
By contrast, Australia suffers from relatively little HIV stigma and provides easily accessible testing and treatment, yet infection rates have increased (pdf) between 1999 and 2008, particularly in Victoria and Queensland. Kippax thinks this is most likely due to a decrease in prevention funding and she fears countries such as PNG with limited resources will have even more trouble resisting the lure of the "prevention is treatment" slogan, choosing instead to invest all their money in treatment.
But "unless money is spent on prevention, we are just going to see HIV prevalence rates go up, country after country, and more and more people on treatment — and countries will go broke," she says.
Sean Slavin agrees that all options need to be investigated, both in Australia and overseas. "This is just another instance in which we need to have a debate, and keep our minds focused on both the history of the epidemic, and the human rights of the people," he says.
At the Australasian HIV/AIDS Conference last week, the scheduled debate took place on the relevance and logistics of implementing ART as prevention in the region. And a world away from messages of hope and progress delivered at conference plenaries, Maura Elaripe, tired of chasing bureaucrats to make sure her special HIV line 2 drugs arrive on time, worries about what the future holds for people living with HIV in PNG.
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