of ‘treatment as prevention’ raises a number of ethical issues, Richard
Ashcroft, professor of bioethics at Queen Mary University of London told the
IAPAC Controlling the HIV epidemic with antiretrovirals evidence summit in
London this week.
the audience that it is rare for a doctor to give a patient a medicine that
will primarily benefit a third party. He went on to highlight situations in
which, at present, antiretroviral treatment is not universally available to all
people who need it for their own health. In such circumstances, why should
treatment’s prevention benefit be “the clincher” that convinces funders
and policy makers to make the drugs more widely available?
At the same meeting, Kevin Fisher of AVAC noted that the ethical concerns tended
to differ in different parts of the world. In settings where there is already
good access to HIV treatment, the concerns are often related to individuals
experiencing external pressure or compulsion to take treatment. In
resource-limited settings, the concerns focused more on the cost of and access
“Prevention is a consequence of treating those in need.” Stefano Vella
Stefano Vella of the Istituto Superiore di Sanità in Italy
said that, in resource-limited settings, working towards universal access to
antiretrovirals was the way to take treatment as prevention forward.
“Prevention is a consequence of treating those in need,” he said.
But there’s also the question of the quality of the
antiretroviral regimens that are commonly used in poorer countries. “We cannot
curb the epidemic with sub-optimal therapies,” he said, pointing to drugs such
as d4T, which are cheaper but have significant side-effects, as well as to people kept
on failing first-line regimens.
In a number of richer countries, the concerns centre more
often on the treatment choices that an individual makes, and how the balance is
struck between the benefits to individual health and those to public health.
This issue is likely to remain unsettled as long as there is
no consensus or clear evidence on whether there is a benefit or harm to the
individual in starting HIV treatment with a CD4 cell count above 350. Secondary
data from the HPTN 052 trial, which will be presented at July’s International AIDS Conference in
Washington, may shed light on this. But the START trial, which was designed to
definitively answer the question, is still recruiting participants and will not
provide results for another four years.
Gus Cairns of NAM reminded the audience that patient choice
is an issue in any treatment decision, with doctors always needing to take it into account alongside their professional duty to care for the patient. Even if the CD4 cell
count is 10 cells/mm3 and the doctor very strongly recommends
treatment, the patient can still make the choice to refuse treatment.
Robert Carroll of the Association of Nurses in AIDS Care
pointed out that if there is a massive expansion in the number of people taking
treatment, there will need to be a corresponding rise in the number of healthcare
workers. Will these new workers be sufficiently trained and have the skills to
support patient autonomy, avoid coercion and understand the impact of stigma? These
are likely to be particular concerns as treatment approaches become ever more simplified
discussion is a theoretical one – the reality is exactly the opposite.” Jorge Saavedra
Equally, Ceri Evans, a sexual health adviser at London’s
Chelsea and Westminster Hospital, commented on the skills and staff time
needed when supporting individuals who are considering personal decisions about
treatment as prevention. For example, when individuals in a serodiscordant
couple are considering stopping using condoms, there may be power imbalances
within the couple that need to be addressed.
Eric Fleutelot of Sidaction said that there were risks of creating
new categories of ‘bad’ people with HIV – those who choose not to take
treatment, or those who don’t adhere to their medication. In places where the law
criminalises HIV exposure (exposing someone to the risk of HIV transmission,
even if transmission doesn’t take place) the law may evolve to recognise the negligible
risk of transmission when a person is on effective treatment. While this would
generally be welcomed, it will add to the social pressure to take treatment.
But some participants felt that some of these anxieties and debates
did not engage with the realities on the ground. Jorge Saavedra of the AIDS
Healthcare Foundation reminded the audience that access to treatment remains a
real problem in the United States. Being denied treatment was a far more
significant problem than being pressurised to take it, he suggested. “This
discussion is a theoretical one – the reality is exactly the opposite,” he
In fact, almost every speaker presented a diagram on the
‘treatment cascade’ – showing how, at every stage, patients are not retained in
the healthcare system or are unable to access the medical care they need. For
example, Kevin Fisher highlighted a US study (illustrated below) which showed that, of the
estimated 1,178,350 people with HIV infection, only 80% are diagnosed. Of those
who are diagnosed, just 51% are linked with a care provider and stay in care.
Of those in care, 89% take HIV treatment, and of this group, 77% achieve a
suppressed viral load, the aim of antiretroviral treatment.
Thus, the bar at far right of the cascade diagram shows that
just 28% of those living with HIV in the United States (328,475 people) have a
suppressed viral load. This means that treatment can only have a limited impact
on the American epidemic. Moreover, it also raises ethical questions about the
inequalities in access to healthcare in the US, with individuals from poor and
marginalised populations being particularly likely to be excluded.
While the equivalent diagram for the UK is more encouraging, it is still only 53% of those with HIV who have an undetectable viral load. This is largely due to problems with undiagnosed infection
– an area where there are important inequalities, with black people and heterosexual men being especially likely to have their infection undiagnosed.