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Treatment is Prevention

In April 2005, the HIV Prevention Trials Network initiated a study called HPTN 052 to evaluate the effect of immediate versus delayed initiation of antiretroviral therapy (ART). The study sought to assess whether early initiation of ART by HIV-infected individuals would reduce HIV transmission to their uninfected sexual partners and whether it would confer any health benefits for the HIV-infected individual.

HPTN 052 was an incredibly important study. The concept of treatment as prevention had hitherto not been assessed in a randomised clinical trial setting. Findings from observational and epidemiological studies had alluded to the potential of treatment as prevention approaches but with HPTN 052, scientists and advocates alike hoped to end any speculation conclusively.

In May 2011, the study’s independent Data and Safety Monitoring Board halted the trial early due to the overwhelmingly positive nature of the study’s findings. The findings showed that early initiation of ART in HIV-infected partners protected their uninfected partners from acquiring HIV with a substantial reduction in risk of 96 per cent. Furthermore, in the group who started ART earlier, fewer cases of extrapulmonary tuberculosis were reported (this finding was statistically significant) and there were fewer AIDS-related deaths.

HIV treatment is HIV prevention.

The study has been the clearest example to date of science driving policy and in late 2011; HPTN 052 was awarded ‘Breakthrough of the Year’ by the journal Science.

The Strategic Investment Framework

If HPTN 052 provided the scientific rationale for placing more people on treatment as an effective prevention strategy; the launch of a Strategic Investment Framework (SIF) by UNAIDS provided the means by which to fund proven prevention strategies through smarter investments.

Given the financial realities being faced by governments the world over, the SIF presented the international donor community with a roadmap which was both achievable and realistic. Based on existing evidence of what works in HIV prevention, treatment, care and support it aims to encourage more strategic use of limited resources.

Modelling aimed at assessing the potential impact of the SIF suggests that its implementation could avert 12.2 million new infections and 7.4 million AIDS-related deaths by 2020. What’s particularly attractive about the SIF is that any increases in investment today are offset by savings in treatment costs alone further down the line. A major weakness of the framework however, is that it does not include the deployment of new HIV prevention technologies, such as AIDS vaccines, in its modelling.

Reactions to the SIF have been hugely positive. As an advocacy tool it aims to help build a case for increased investments in HIV/AIDS today, particularly in HIV treatment, in order to make savings in the future.

In the UK, the Coalition Government has been increasingly calling for value for money in its overseas development assistance programmes. Initially sceptical about the SIF, the UK Department for International Development (DFID) described it as “a very useful approach… up-front investment is justified by the decline in investment needed in later years.”

In the SIF, advocates now had the very ammunition they needed to support a treatment as prevention approach, backed at the highest level through UNAIDS.

Political Groundswell

2011 marked the 30^th anniversary since the discovery of AIDS. In July 2011 the United Nations General Assembly held a High Level Meeting on AIDS to reflect on successes and learn from opportunities missed as part of the 2001 Declaration on Commitment and the 2006 Political Declaration on AIDS. The outcome of the meeting was a commitment to place 15 million people on ART by 2015. World leaders also agreed to deploy biomedical interventions as soon as they are validated.

The political picture was improving. In parallel a number of global campaigns, focused mainly in the US, got underway that aimed to influence governments to articulate their commitment to eliminating AIDS in the face of years of waning political interest. Of particular note is the actions of a collation of NGOs including the One Campaign, RED, RESULTS and ACT V – a new advocacy movement to end AIDS. Using the findings of HPTN 052 and the new Strategic Investment Framework, the US advocacy coalition argued that more people could be put on treatment without the government necessarily having to increase their investment.

The first signs of hope came in November from Secretary of State, Hillary Clinton. In a landmark address she called on the world to usher in an AIDS-free generation, “This goal would have been unimaginable just a few years ago…yet it is possible because of scientific advances. While the finish line is not yet in sight, we know we can get there, because we know the route we need to take.” Secretary Clinton’s speech made the creation of an AIDS-free generation a US policy priority.

This announcement was swiftly followed by one from President Obama himself on World AIDS Day. In his speech, President Obama delivered exactly what the US advocacy coalition had been calling for – an additional 2 million people on ART by 2013.

The end of AIDS?

Approaching World AIDS Day many advocates and movements began to articulate a new narrative – the end of AIDS. It seemed that overnight, advocates were calling on governments to end AIDS within a generation. A wave of optimism had reinvigorated the global AIDS movement inspired largely by new science.

The Global Fund in Crisis

The biggest obstacle in this wave of optimism came late in 2011 and from left field. Amid the joy of ‘new science’ to end AIDS, renewed political commitments and a realistic investment framework to make it all happen, came the news that the Global Fund was in crisis.

Shortly before World AIDS Day, the Global Fund’s Board announced that due to funding shortfalls it would have to skip funding new proposals in its 11^th Round. The Global Fund has never had to make such a decision since its inception in 2002.

The situation at the Global Fund is still fluid but the Board has announced that it will create a transitional funding mechanism. The transitional fund will allow countries facing disruptions to their HIV programmes to apply for funding that will cover essential needs only. This means that transitional funding can only cover people who are already on ART, it does not apply to putting new people on treatment.

As it stands, the Global Fund will not be able to fund new treatment until 2014 at the earliest. The crisis has since triggered a governance shake up with the departure of Michel Kazatchkine and the employment of a new General Manager. As Dave McCoy puts it:

This is a significant and even bewildering time for the Global Fund. It is undergoing not just a financial and fiduciary crisis, but also a process of transformation. And multiple agendas are in play…It is too early to predict the final impact of all the changes. However, given the unclear (and, at times, contradictory) nature of the changes, there is still some opportunity to shape the eventual outcomes of the transformation.

RESULTS UK in an open letter in the Guardian claimed that cancelling Round 11 was like throwing away the huge gains of recent years. They pointed out the irony of donors significantly cutting their funding pledges in the face of the Global Fund making great strides to improve fiduciary control, risk management and governance. Oxfam in their response to the crises said that political commitments made at the UN High Level Meeting were worthless without additional resources.

The International HIV/AIDS Alliance in a December press release demanded that the Global Fund Board and Secretariat find the necessary resources through a new funding opportunity in 2012, estimated at US$ 2 billion. The Alliance called on the Global Fund to hold an emergency donor conference and to issue new calls for proposals ahead of the International AIDS Conference in July 2012.  From the 1^st January, they articulated their call to action as “200 days to save the Global Fund”.

What does it all mean?

HPTN 052 is an excellent example of science driving policy because it connected with advocates and policy-makers around a shared problem: how do we convince donors to stump up the cash to place more people on treatment in times of financial austerity? HPTN 052 in concert with approaches such as the Strategic Investment Framework provided the answer.

Undoubtedly treatment as prevention is a tremendous breakthrough but amid the noise generated by the global AIDS community no-one is finding space to point out that alone it cannot bring an end to AIDS. If we are serious about ending AIDS we need to adopt a combination prevention approach which takes account of what we know now and the resources and tools we have available today; while keeping an eye on future needs, such as new prevention technologies like an AIDS vaccine.

What’s clear is we need to maintain the political momentum, more effectively learn from the communities most affected by HIV/AIDS and invest in and encourage innovation in scientific discovery. We also need to get better at implementing and monitoring complex and multifaceted prevention programmes.

But if we don’t have the money, we don’t have the means to implement any of this. Let us hope we can sustain and accelerate the momentum generated in 2011. We can. We will. End AIDS.

About the author

Gavin Stedman-Bryce is founder and director of Pamoja, and provides policy advice for Act V and the International AIDS Vaccine Initiative.