ART as Prevention
HPTN 052 was a large study that recruited couples where one partner had HIV,
and the other did not, 1763 couples in total from Malawi, Zimbabwe, Botswana,
Kenya, South Africa, Brazil, Thailand, the US and India.
The study looked at whether starting ART soon after the
parter with HIV was diagnosed (in this study when their CD4 cell counts were
between 350 and 550) reduced the chances of their partner becoming HIV
infected, compared to waiting until their CD4 cell count dropped to < 250 to
start ART. Reported condom use was high at the start of the study and remained
high during the study
– so any effect was due to ART.
The good news?
Starting ART early reduces HIV transmission in a BIG way
by 96%. The only transmission that occurred from a person on treatment is
believed to have occurred within the first few weeks on ART, before HIV was
What does this mean
Nurses prescribing ART and other healthcare staff scaling
up and improving the quality of ART services should know that they are also
helping to reduce new HIV infections. Early diagnosis, prompt referral for ART if eligible, retention in care, and adherence to treatment are all essential for treatment as prevention to show its full potential. Tip: Partnering with trained community
health workers and expert patients helps achieve the best retention in care and
The ART as Prevention news makes a good case for starting ART
earlier in people living with HIV. Policy changes have happened in some
countries, for example:
- Malawi: Even
before the results came out, Malawi announced that it would provide universal
lifelong ART to any HIV-positive woman entering their PMTCT programme 1) for
– studies show ART reduces maternal mortality, 2) to prevent the
spread of HIV to the infant she is currently pregnant with, 3) to better prevent
the infection of any subsequent children she might have by providing protection
from conception on, and 4) to help her keep her partner uninfected, if he
doesn’t already have HIV. Unfortunately, this programme is jeopardised by
recent HIV funding cuts.
- Rwanda and Zambia
are now offering ART to any person in a serodiscordant relationship, should
they and their partner want it. This follows naturally from their policies on
couples HIV counselling and testing.
WHO and other countries are considering policy in light of
these results. Many programmes are busy expanding to put people who immediately
need ART to stay alive, and need to plan carefully to find the money to sustain
current programmes first, before widening eligibility criteria for ART. But it is
hoped that the ART as Prevention news increases support for the HIV programmes
and importantly, the health system that provides it, both from the national
government and international donors.
Although the results do not nearly seem as
profound, two studies also showed that PrEP may be an alternative or
supplemental option to protect HIV-negative people who may have a partner, or
sexual partner with HIV. (Read the news report here).
Partners PrEP study compared tenofovir and tenofovir/emtricitabine (Truvada)
versus placebo as PrEP in serodiscordant couples in Kenya and Uganda, while the
TDF2 study compared Truvada versus placebo in heterosexual men and women in
the Partners study found that tenofovir reduced the HIV infection rate by 62%. Truvada
reduced the infection rate by 73%; there was no statistical difference
between the efficacy of Truvada and tenofovir.
In the TDF2
study, Truvada reduced the infection rate by 63%, but by 78% in patients who
had picked up their study drugs within the previous month and who therefore had
PrEP to prevent sexual
transmission of HIV is still considered an experimental approach, and in
particular, further study is needed in women to understand why it seems to work
in some studies but not others.
When resources for ART as treatment and prevention are limited, PrEP may seem less of a priority but it
may be an important option for some people. For instance, it may offer
increased protection for the seronegative partner over and above ART as
Prevention, such as when a couple is trying to conceive but cannot afford
access to safer but high tech fertilisation methods (see below). More research
breastfeeding HIV-exposed infants
PrEP in breastfeeding infants is NOT an experimental
approach however, and in Rome,
an analysis of data from several major studies showed that extending the use of
nevirapine or zidovudine and nevirapine in infants can reduce the risks of HIV
transmission through breastmilk by over 70%. (Read the news report here).
from these studies showed that giving HIV-exposed infants daily nevirapine could
help protect them from HIV transmission through breastmilk and led the World
Health Organization (WHO) to change its guidelines in 2010.
the analysis found that the longer you give nevirapine prophylaxis to infants
who continue to be exposed to HIV through breastfeeding the more HIV
transmission is reduced, and it should probably continue as long as the
HIV-exposed infant is breastfeeding.
WHO recommends exclusive breastfeeding
for six months with the introduction of complementary foods for the next six
months. Breastfeeding should stop at the end of 12 months, if feasible. Rapid
weaning is no longer advised.
This is not the national
policy in every country, so healthcare staff are advised to consult with their