London School of Hygiene & Tropical Medicine

"The past year has seen some important advances in HIV prevention research and the recently released UNAIDS data on HIV infection rates are grounds for cautious optimism. However, with 33 million people infected with HIV worldwide, over two-thirds of them (22.5 million) in sub-Saharan Africa, HIV control remains a key global priority. Despite important progress in rolling out HIV treatment to more of those who need it, there are two new HIV infections for every HIV-positive patient started on HIV treatment. Unless we can find more effective ways to prevent these new infections, we will have ever-increasing numbers of patients needing treatment, and it will become increasingly difficult to sustain these services.

Yet now we have promising new tools for HIV prevention that may help us turn the corner in the fight against HIV. This World AIDS Day let us reflect only briefly on the past but more importantly plan strategically for the future. Although good work has been done at both global and country levels over the past thirty years, in order for us to gain an advantage over the epidemic during the next thirty years, it is imperative that there is continuing support for HIV research and that researchers design and evaluate innovative approaches to prevent the transmission of HIV in the area of the world where it is needed most.

One promising approach is to get many more HIV-positive individuals on to HIV treatment much earlier than at present, using HIV treatment as a preventive measure. We know that effective HIV treatment can reduce the amount of HIV virus in the body to a very low level and this greatly reduces their chances of passing the virus on to others. If a large enough number of people in a community are tested for HIV and if HIV-infected individuals are offered treatment straightaway, this could dramatically reduce the rate of new infections.

This strategy is set to be tested in the upcoming PopART trial. The trial aims to implement and evaluate an intensive combination HIV prevention package which will be offered to entire communities and will be carried out in 15 communities in Zambia and 9 communities in the Western Cape of South Africa over the next five years.

The PopART approach includes providing voluntary HIV testing and counselling through house-to-house campaigns, offer of male circumcision to men testing HIV-negative (this is known to be partially protective against HIV) and the offer of immediate HIV treatment to all those testing HIV-positive regardless of their CD4 count. By offering this package of services to the entire community, it is hoped this will prevent the stigmatisation of infected individuals and reduce the need for specially targeted interventions for specific risk groups.

There is a strong rationale for the PopART approach. Its predecessor, HPTN 052, showed that early HIV treatment – started at a CD4 count between 350 and 550 – reduced the risk of HIV transmission to an uninfected partner – by 96%. It also provided health benefits for the treated partner.  

What we now need are rigorously conducted large-scale trials, like PopART, to determine how well such strategies can be delivered in practice and to find out what impact they have on HIV spread at population level. These trials cost time and money, two resources that are being rapidly exhausted. This is the new reality we must face. But the results have the potential to save millions of lives, and even – in the longer term – to save money, because of the possible steep reductions in the number of new infections needing treatment in the future.

Thirty years into the HIV epidemic, radical ideas are needed to tackle this wide-reaching problem. The PopART trial is one of these which, if successful, has the potential to move us years ahead in the fight to roll back HIV."