22 February 2016
The HIV world is used to things moving fast, in a way that most medicine just doesn’t.
The reasons for this are complex, but include: strong research funding, focused and effective activism, and often younger, more dynamic and ambitious health professionals who recognised the inability of modern medical delivery systems to get treatment right.
Whatever it was, 2015 was a stellar year for HIV breakthroughs, even when measured against previous years. We now know:
We should treat everyone. The HIV world’s longest running debate, about at which CD4 number (a measure of immunity) to start, was finally settled. Even at high CD4 counts, there is benefit from antiretroviral therapy (anti-HIV drugs, known as ART) against TB, pneumonia and cancer. The South African private sector will move to starting ART whenever someone is ready; the public sector is expected to follow suit soon after.
HIV cure research has a long way to go. Although there were several cases of supposed cure in babies and adults, the virus came back every time. The exception was one man, who is the only known case of cure. But, huge research efforts are underway to try to untangle how to get it right.
Life expectancy in HIV-positive people is pretty much normal on ART, especially if you start before you get sick or your CD4 count falls low. Studies from South Africa and other African countries, as well as from Europe and the US, have demonstrated life expectancies extending into your 70s and 80s. So, plan for grandkids and get those retirement annuities in.
Modern treatment has never been safer. Less than 5% of people on ART now have to have switches in treatment, and they then have lots of other options.
Modern treatment looks to be getting better still. New drugs mean smaller tablets which don’t require the high adherence levels required with current treatments. Some of these will be available in the private sector probably in the next few months, and soon in the public sector. There are even preliminary results (it’ll be a few years before available) on a new injectable antiretroviral combination, which means, like contraception, you can choose between a daily tablet or an injection every few months.
We might need only two drugs or even one. The new drugs are so powerful, we might no longer need the three we’ve been using for 15 years. Do NOT try this at home, though, until the research is in.
Treatment comes with a huge prevention benefit. HIV-positive people who have their virus fully suppressed on ART do not sexually transmit the virus.
The drugs work in HIV-negative people too (called ‘’pre-exposure prophylaxis’’ or PrEP). Another huge breakthrough has been that giving antiretrovirals daily to HIV-negative people at high risk of getting HIV (a bit like how we give contraception to prevent pregnancy) has been shown to work very well.
PrEP studies are happening in South Africa on gay men and sex workers, and the government is examining this as a country-wide option. But, the group that most needs it is young women, and different delivery models for PrEP are being looked at. We will have news this week on a long-acting vaginal ring that may deliver PrEP a little like the IUD delivers contraception.
HIV is still at catastrophic levels. New HIV infection rates are still very high in South Africa, with seven million HIV-positive people. While condoms and male circumcision work, it seems it is not enough, and a vaccine, while hopeful, is some way away. The South African government has committed to the UNAIDS/WHO 90-90-90 targets (90% of people to know their status; 90% on treatment, and 90% of these are virally suppressed). Mathematical modelling suggests that this aggressive approach to treatment, with an expansion of PrEP, male circumcision, and continued condom provision, will be enough to bring the epidemic under control in the next few decades.