Early HIV Drug Therapy 'Significantly Reduces' Transmission to Partners
This week the AIDS world received the stunningly encouraging results of the HPTN 052, a randomized, phase 3 clinical trial, which confirmed what many public health experts have long believed: that early HIV treatment not only benefits the person infected but also reduces the likelihood that he or she will transmit the virus to sexual partners.
Termed "treatment as prevention," this approach adds to the rapidly expanding range of prevention and treatment options that, used in concert, many believe, could help break the back of the worldwide HIV/AIDS epidemic. While the HPTN 052 trial results have been widely reported in the mainstream media--from the New York Times to the Wall Street Journal--here we examine their implications for Black America.
The HPTN 052 clinical trial's findings have dramatic implications for the HIV epidemic in the United States, whose epicenter now sits in Black America.
Blacks represent only 13 percent of the U.S. population but account for 45 percent of new HIV infections, according to the Centers for Disease Control and Prevention. African Americans are eight times more likely to be diagnosed with HIV than Whites and experience the highest rate of AIDS and AIDS deaths (pdf). They also suffer far more HIV-related health disparities than the population at large.
So might Black Americans benefit disproportionately from the more aggressive antiretroviral (ARV) therapy suggested by the HPTN 052?
"That is exactly what we have been talking about for some time," said Anthony Fauci, M.D., director of that National Institute of Allergy and Infectious Diseases, in a telebriefing with reporters. "There is a great disparity in the African American community. This is a good scientific reason why we should do this."
Proof That Treatment's Benefits Transcend the Individual
Compared with the rest of the world, American doctors often initiate antiretroviral treatment early--when an individual's CD4 count, a measure of immune system strength, falls below 500 per cubic millimeter. That's a higher threshold than the World Health Organization's international guidelines of 350.
Yet large numbers of Black people are not diagnosed HIV positive until after they've been HIV positive for years. African Americans make up some 56 percent of all so-called late testers--people who are diagnosed with AIDS within one year of their HIV diagnosis. Not only do late testers have less chance to benefit from lifesaving ARVs, but they are "considered extremely infectious, because they typically have massive amounts of the virus" in their bodies, the Wall Street Journal notes. The sooner the person is treated after diagnosis, the less likely he or she is to infect others.
And whether or not they are tested late, many PLWHA elect to delay treatment until their CD4 count drops below 350 or they experience symptoms of an AIDS-related disease.
The HTPN 052 trial's finding that early treatment reduced HIV transmission by 96 percent strongly suggests that treatment's benefits transcend the well-being of the infected individual. "This tells us that the decision [about when to start treatment] has less to do with what is good for [the HIV-positive person] and [more] with what is the extra benefit concerning transmissibility" to others, said Dr. Fauci.
Aggressive testing is key to neutralizing some of the HIV-related health disparities that Black people experience, Dr. Fauci added: "Get out there, find out who is infected with voluntary testing, and link them to care and therapy as soon as possible."
The HIV-Prevention Toolbox Explodes
The HPTN 052 results become the latest HIV-prevention technology to make headlines in recent months--from the landmark microbicide research announced at the 2010 International AIDS Conference to the recent data on the potential of pre-exposure prophylaxis (PrEP) to help protect gay and bisexual men. Several key advances toward discovering a preventive HIV vaccine have also occurred in recent weeks.
"The prevention toolbox has just exploded," says Phill Wilson, president and CEO of the
Black AIDS Institute. "This study definitively ends the debate of prevention versus treatment. Prevention and treatment are inextricably connected: Treatment is prevention."
"These data must serve as a clarion call to funders, policy makers, civil society and implementers," Mitchell Warren, executive director of New York City-based AVAC, formerly known as the AIDS Vaccine Advocacy Coalition, said in a statement. "If deployed effectively, efficiently and ethically, early initiation of treatment will be fundamental to turning the tide of the epidemic."
ADAP, Disclosure and Stigma: Front and Center
Bambi W. Gaddist, Dr.P.H., founder and executive director of the South Carolina HIV/AIDS Council, which serves a largely African American and low-income client base, endorses the HPTN 052 findings--with a proviso. "I am elated that the NIAID study officially confirms what we already knew," says Dr. Gaddist. The findings will serve as the "premise for our position as HIV/AIDS activists when we interface with congressional and state leadership who fail to support ADAP," she adds.
The AIDS Drug Assistance Program (ADAP) is the federal-state partnership that helps low-income people living with HIV/AIDS pay for their expensive, lifesaving medications. Recently a number of states have slashed funding for ADAP, whose participants are disproportionately Black.
But testing and treatment are only one part of the equation. "The discussion of disclosure will become a greater imperative in light of these supportive findings," says Dr. Gaddist, who worries that the HPTN 052 results could lead some to develop a false sense of security.
"These outcomes should accompany a national discussion of reducing HIV/AIDS stigma--so that the community will uphold the ideals of prevention," Dr. Gaddist adds. "If we move to this mind-set, these medicines will not be needed in the first place."
Wilson believes that the AIDS movement has reached "a deciding moment" in the pandemic's 30-year history. "We have the tools to end the AIDS epidemic," he says. "The question is whether we have the political will and compassion to make the investment necessary to use them."
Rod McCullom, a writer and television news producer, blogs on Black gay, lesbian, bisexual and transgender news and pop culture at rod20.com.