Universal testing and treatment will not stop the HIV epidemic

According to Salim Abdool-Karim, MD, ChB, PhD, of the Center for AIDS Research in the South, universal testing and treatment strategies have resulted in "modest or no reduction" in new HIV transmissions in three major areas. population-based studies Africa, in a comment posted online today in the New England Journal of Medicine.

But that does not necessarily mean that expanding diagnoses and providing immediate access to anti-HIV drugs does not stop HIV transmission, said Myron Cohen, MD, of the Faculty of Medicine at the University of Toronto. 39, University of North Carolina at Chapel Hill.

"We would never get out of the epidemic," said Cohen, who did not participate in the trials, Medscape Medical News. "The message to remember is that it's the right thing at the right time, but it's not enough."

Cohen has been at the center of this conversation since 2011, when the study for which he was the principal investigator, HIV Prevention Trials Network 052 (HPTN-052), showed that the treatment of a person living with HIV prevented that person from transmitting HIV to others.

By the time HPTN-052 reported its final results in 2016, studies to test the concept that treatment preventing transmission was underway were already underway. And ministries of health in several countries were following the evolution of universal tests and treatments and their impact on the number of new infections. In 2017, the Kingdom of eSwatini (formerly Swaziland) announced that a drastic scaling up of treatment led to a 44% decrease in new infections, as reported Medscape Medical News.

The American ambbadador Deborah Birx, MD, said at the time: Medscape Medical News that the data is "a real and documented proof that you can translate science into programs".

Today, the New England Journal of Medicine published three studies that rely on these data. The studies were presented separately at the 2019 Conference on Retroviruses and Opportunistic Infections and the 2018 International AIDS Conference.

"A debate ensued when mathematical models predicted that universal screening and treatment could help control epidemics in a few years in the most affected environments," Abdool-Karim writes in his commentary. Unfortunately, the predictions of the models did not succeed.

"In this issue of Newspaper, three trials of universal tests and treatments show varying results, ranging from a modest reduction to an absence of HIV incidence, "Abdool-Karim writes.

Table. HIV test reduction test by universal test and treatment (UTT)

CMVM = voluntary male medical circumcision; NCD Tx = treatment of noncommunicable diseases; PCC = patient-centered care; ASC = community health worker; * Listed as "not significant"; ** at 24 months

Even authors of the study, such as the authors of PopART (HPTN 071), write that they were "surprised" that more intensive treatment in a group of the test did not occur. results in almost no difference between the control group and the intervention group. And even studies that have shown a substantial drop in the incidence of HIV, such as that of Ya Tsie, revealed that it was not statistically significant at the end of the three years of the year. ;trial.

So what does all this mean? For Abdool-Salim, this means that "programs must consider going beyond universal testing and treatment, but testing, treatment, and prophylaxis to control the HIV epidemic ".

In addition, he highlights four ideas from the essays. The first is that universal testing and treatment have been effective in increasing viral suppression in people living with HIV. He added that the lack of statistical significance could be related to what was happening in the control groups – and in the countries – while trials were underway.

In the Ya Tsie trial, for example, at the beginning of the trial, one of the usual treatments was to initiate antiretroviral treatment (ART) as soon as the CD4 count was less than 350 cells / mm.³ or if the viral load was greater than 10,000 copies / mL. But in 2015, the country started treating everyone – including those in the control group – when CD4 levels were higher, at 500 CD4 cells / mm.³. At the end of the trial, the law of the land was universal testing and treatment. It was the same at the end of the PopART and SEARCH trials.

This, says Cohen, "raises the bar" for viral suppression and reducing the incidence of HIV in trials. For the interventions to have the desired impact, the basic HIV incidence would have had to be relatively stable.

But "the standard of care is not stable," Cohen said. "It would be unethical and unacceptable not to touch the standard of care[À350cellules/mm[At350cells/mm[à350cellules/mm[at350cells/mm³ or above]just because there are trials going on. "

Abdool-Karim then points out that it's real life. In randomized controlled trials such as HPTN-052, they were able to prove that the treatment prevented transmission because they could match the virus in the person living with HIV to the person who had acquired it during the course of treatment. # 39; test. If people contracted HIV, they were excluded from the calculations. Abdool-Karim referred to a trial conducted in South Africa in 2018, where 35% of new HIV infections "were identified phylogenetically as coming from outside the test area".

New infections may not come from people treated in the trials.

Third, Abdool-Karim wonders whether tests and treatment trials have captured enough people early enough for their infection to stop spreading. Identifying and treating people with a long-term, less virulent infection can not prevent spread in hot spots.

Finally, he asked if those who had been successful in suppressing viruses in clinical trials were those who were more likely to engage in behaviors that could transmit the virus. For example, SEARCH specifically targeted people under 25 and men. Nevertheless, despite everything, men and young people were always less likely to be virally repressed than their older counterparts or more female.

Cohen agreed.

"It's not that people treated do not need treatment," he said. "Not surprisingly, many young people have a much higher rate of acute and early infection, so their viral load is higher, [and] they are more badually active. "

Cohen said the universal test and treatment model is already out of the bag.

"We will not stop doing universal tests and treatments," he said. "So the question is now, how can we get more for our money?"

The Ya Tsie and PopART trials were both funded by the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Mental Health (NIMH), the National Institute of Addiction (NIDA), the US President's Emergency Plan for AIDS PEPFAR, the International Initiative for Impact Evaluation and the Bill and Melinda Gates Foundation. The SEARCH trial was funded by PEPFAR and the National Institutes of Health. Cohen says he has received advisory board fees or travel reimbursements from Janssen Global Services, Roche Molecular Systems and Merck Research. Abdool-Karim has revealed no relevant financial relationship.

NEJM. Posted online 17 July 2019. Ya Tsie Abstract, Abstract PopART, abstract SEARCH, Editorial

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