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Is HAART modifying the HIV epidemic? HAART for Prevention
 
 
  The Lancet Aug 14 2010
 
Franco Maggiolo aEmail Address, Sebastiano Leone a a Division of Infectious Diseases, Ospedali Riuniti, 24128 Bergamo, Italy
 
"When antiretroviral use expanded, because of initial roll-out of HAART (1996-99), or because more aggressive treatment guidelines were implemented (2004-09), new HIV diagnosis per year decreased sharply (40% and 23%, respectively).....The beneficial effect of HAART in epidemic terms occurs because the widespread use of antiretroviral drugs reduces, at a population level, the average viral load, translating into an average reduction of infectivity and transmission.9, 10 To obtain these results, two conditions are fundamental. First, the availability of potent effective drugs that could prevent the selection of resistant mutants over time, and second, effective programmes to identify HIV-infected individuals who are unaware of their status. The latter group is nowadays the most demanding problem, and today's data draw attention to this challenge."
 
Full text of Montaner Study in Lancet:
 
Association of highly active antiretroviral therapy coverage ...Jul 18, 2010 ... Prof Julio SG Montaner MD, ... rationale for re-examination of the HIV prevention and treatment dichotomy, ... "Our results support the proposed secondary benefit of HAART used ... www.natap.org/2010/IAS/IAS_07.htm
 
' Start HIV Therapy Earlier, IAS-USA Panel Recommends'Jul 21, 2010 ... Thompson MA, et al "Antiretroviral treatment of adult HIV infection: 2010 Recommendations of the International AIDS Society-USA Panel" JAMA ...
 
In 2008-according to the Joint UN Programme on HIV/AIDS-33 million people were living with HIV, and 2·7 million more were infected.1 Although 68% of infected people live in sub-Saharan Africa, the HIV challenge is common in many parts of the world; so why, 27 years after the discovery of HIV, does the epidemic remain uncontrolled?
 
So far, biomedical interventions to interrupt viral transmission have been disappointing, and risk-reduction strategies that used information, education, and behavioural changes have produced unsatisfactory results.2, 3 The preventive benefits of highly active antiretroviral therapy (HAART) in the general population have been greatly discussed. The extent of benefit depends on the proportion of HIV-infected individuals treated, the ability to provide therapy to patients most likely to transmit HIV, the extent of viral-load control, the emergence of drug-resistant strains of the virus, and the effect of treatment on risk behaviours. Although several mathematical models have explored the effect of HAART on the HIV epidemic, the true practical effect has yet to be verified.4
 
In The Lancet today, Julio Montaner and co-workers5 report a comprehensive epidemiological analysis in British Columbia, Canada. In this province, the number of individuals receiving HAART increased from 837 to 5413 (+547%, p=0·002) from 1996 to 2009. In the same period, individuals newly testing positive for HIV decreased from 702 to 338 per year (-52%, p=0·001). Moreover, the researchers identified a link between HAART use and new HIV diagnoses. When antiretroviral use expanded, because of initial roll-out of HAART (1996-99), or because more aggressive treatment guidelines were implemented (2004-09), new HIV diagnosis per year decreased sharply (40% and 23%, respectively). However, when HAART use increased slightly (2000-03), because of a relative balance between patients on HAART or interrupting treatment, the frequency of new diagnosis remained stable (+5%). The investigators also noted a link between HIV-RNA concentrations (eg, proportion of individuals with viral load <500 copies per mL), and the proportion of new HIV-positive tests. Finally, they noted that their results were mainly driven by a significant decrease per year in those with a previous history of intravenous drug use, whereas the incidence of new positive tests in individuals with other risk factors for HIV was unaffected.
 
Nurse prepares drugs for patients at Keiskamma Trust treatment centre in village of Hamburg, East London, South Africa
On an individual basis, HAART gives impressive results, improving the quality of life and survival of infected patients.6 Here we face an alternative use of HAART-as an epidemic-control strategy to improve public health and reduce infectivity or transmissibility of the infection. Assumptions behind this use include the obvious fact that HIV transmission occurs only through HIV-infected individuals, and that viral load is the most relevant risk factor for any method of transmission.7, 8
 
The beneficial effect of HAART in epidemic terms occurs because the widespread use of antiretroviral drugs reduces, at a population level, the average viral load, translating into an average reduction of infectivity and transmission.9, 10 To obtain these results, two conditions are fundamental. First, the availability of potent effective drugs that could prevent the selection of resistant mutants over time, and second, effective programmes to identify HIV-infected individuals who are unaware of their status. The latter group is nowadays the most demanding problem, and today's data draw attention to this challenge.
 
The results of today's analysis were mainly driven by the reduction of new infections in patients with a history of drug use, who might be more aware of the risk of HIV infection and might have more contacts within the health-care system, and therefore a greater chance to be screened for HIV infection.
 
HAART might prove effective within other risk populations,11 provided that the source individuals are thoroughly identified and correctly treated. Therefore we must couple the use of antiretrovirals with risk-reduction strategies, and identify infected individuals through information or education interventions that favour individual access to screening programmes. Integrated experiences that provide voluntary routine HIV testing and rapid entry into care, such as those recently implemented in Washington, DC,12 would tell us whether HAART can succeed as an epidemic control measure.
 
While waiting for an effective vaccine, experiences such as those reported today should be strongly considered by clinicians, national and international agencies, policy makers, and all parties involved in the development of treatment guidelines, because the population-based dimension of HAART might play an important part in the future control of the HIV epidemic.
 
FM has served as a consultant on advisory boards for Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Roche, and Tibotec; has received lecture fees from Abbott, Bayer, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Merck Sharp and Dohme, and Roche; and has received research and educational grants from Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Jansen-Cilag, and Roche. SL has received educational grants from Pfizer and Wyeth Lederle.
 
 
 
 
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