WHO Meeting to Evaluate Test-and-Treat Strategy

Nearly a year after a quintet of researchers from the World Health Organization (WHO) published an article in The Lancet describing the results of a mathematical model that predicted that a combination of annual HIV testing and immediate antiretroviral (ARV) treatment could potentially end the AIDS epidemic in 50 years, scientists, public health officials, and community activists gathered November 2-4 to talk exclusively about the strategy dubbed test and treat (see VAX July 2009 Spotlight article, Test and Treat on Trial).

The WHO convened the meeting in Geneva, Switzerland, to stimulate discussion about the ethical implications, acceptability, and feasibility of implementing the test-and-treat approach in various populations. Although the strategy looks promising based on mathematical models, it has not yet been subjected to the rigors of a randomized, controlled clinical trial.

The experts who gathered in Geneva included Julio Montaner, president of the International AIDS Society, who is a vocal advocate of early initiation of ARV treatment and has been studying the impact that expansion of ARVs has had on lowering community viral load and HIV incidence in Vancouver, British Columbia. Community viral load reflects the mean viral load of a group of HIV-infected individuals. Montaner said a study that looked at the effect of expanding ARV treatment from 3,500 HIV-infected individuals to 5,000 in a community in Vancouver appears to have had an impact on transmission. “All I am prepared to say right now is that new HIV infection rates are going down,” said Montaner.

Next Spring, US researchers are hoping to launch a pilot study, known as HVTN 065, to evaluate the feasibility of implementing test and treat in Washington, D.C., which has the highest prevalence of HIV in the country, and the Bronx in New York City, which has the highest AIDS death rate of the city’s five boroughs due to the fact that so many HIV-infected individuals there are diagnosed late. The three-year study will occur in high-risk communities where poverty, racial discrimination, AIDS stigma, distrust of doctors, and other factors can be barriers to accessing medical care. Wafaa El-Sadr, director of the Center for Infectious Disease Epidemiologic Research at Columbia University’s Mailman School of Public Health, will be heading up the pilot study, which is being funded by the US National Institute of Allergy and Infectious Diseases (NIAID) and reflects a collaborative effort between NIAID, the US Centers for Disease Control and Prevention, and local health departments in the two cities.

El-Sadr said the goals of the study are to determine the best way to link HIV testing and treatment programs, to retain HIV-infected individuals in treatment programs, and to ensure individuals adhere to their daily ARV regimens.

“What I got from the [WHO] meeting was a collective commitment of the importance of continuing to expand access to treatment,” said El-Sadr. “Only about 40% of people who need treatment today can obtain it. We have a long way to go.”

Mark Harrington, an activist who heads the Treatment Action Group in New York City, said at the very least, test and treat may provide better linkage between prevention and treatment. “Care and treatment and prevention need to be done altogether.”