Published: Oct 23, 2013
By Michael Smith, North American Correspondent, MedPage Today
The prospect of a world without AIDS is real, but getting there won't be easy.
That's the bottom line in a series of papers on the topic published in three journals in advance of a translational medicine conference on the topic slated for early November in San Francisco.
"Achieving an AIDS-free world is no longer an idealistic aspiration -- it is an achievable goal," argued Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases in Bethesda, Md., and Hilary Marston, MD, also of the institute.
But getting there will require "effective implementation" of current ways of preventing AIDS, combined with finding new interventions, Fauci and Marston argued online in Cell and The Lancet.
And the path forward, while now at least partly visible, remains littered with roadblocks.
For instance, evidence is mounting that highly active antiretroviral therapy (HAART) can dramatically inhibit the transmission of HIV between sexual partners.
In principle, if every person infected with HIV were immediately to start taking appropriate medications, the progress of the HIV/AIDS pandemic could slow and begin to reverse, argued Myron Cohen, MD of the University of North Carolina in Chapel Hill, and colleagues.
But, they wrote in The Lancet, "challenges to this approach are substantial."
For so-called treatment-as-prevention to work, they argued, will require universal access to medications that begins soon after a person is infected with HIV.
But "not all HIV-infected individuals can be located, especially people with acute and early infection who are most contagious," the investigators noted.
Current guidelines in the developed world call for HIV treatment to be started as soon as possible after diagnosis, but not all countries have embraced the idea, they added.
"Some experts do not believe that immediate or early (therapy) is justified by present evidence, or that healthcare infrastructure for this approach is sufficient," Cohen and colleagues wrote.
An important issue is how widely the idea of treatment-as-prevention applies. The major study -- one led by Cohen -- showed a 96% reduction in the risk of transmission among heterosexual couples in which one partner was HIV-positive and the other was not.
But the ability of antiretroviral therapy to cut transmission among men who have sex with men (MSM) and injection drugs users remains to be seen, the investigators noted.
Indeed, stable HIV incidence in some communities of MSM where antiretroviral therapy is established and widely used "emphasizes the concern that not enough is known about treatment as prevention for this crucial population," they argued.
While treatment-as-prevention has scooped recent headlines, HAART also has its original use -- preventing the progression of HIV infection to full-blown AIDS, argued researchers led by Steven Deeks, MD, of the University of California San Francisco.
Properly followed, they pointed out (also in The Lancet), HAART prevents a host of AIDS-related illnesses. However, "a new set of HIV-associated complications has emerged, resulting in a novel chronic disease that for many will span several decades of life."
The therapy doesn't completely restore the immune system, they noted, so that complications such as cardiovascular disease and cancer are becoming more important among HIV patients.
Moreover, anti-HIV drugs themselves have cumulative toxicities that -- over years of treatment -- "can cause clinically-relevant metabolic disturbances and end-organ damage."
Especially in developing countries, the "multimorbidity" associated even with properly treated HIV could overwhelm some healthcare systems, Deeks and colleagues argued.
The holy grails of HIV research -- a vaccine and a cure -- remain elusive, Fauci and Marston commented, but intense research is underway on both fronts.
There has been some halting progress toward a vaccine, they noted, and a cure for HIV "is no longer beyond the imagination."
Primary source: The Lancet
Source reference: Cohen MS, et al "Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: Where do we go from here?" Lancet 2013; DOI: 10.1016/S0140-6736(13)61998-4.
Additional source: The Lancet
Source reference:Deeks SG, et al "The end of AIDS: HIV infection as a chronic disease" Lancet 2013; DOI: 10.1016/S0140-6736(13)61809-7.
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