Updated 30 November 2015

South Africa mulls earlier HIV treatment as study confirms antiretrovirals prevent HIV

Currently, South Africans must wait until their CD4 counts drop to 500 or below before starting ARV treatment. A new study shows people should be started on ARVs as soon as they are diagnosed with HIV in a strategy called “test and treat.” This would reduce the infection rate.

HIV treatment can reduce your risk of transmitting the virus to others by 93 percent, according to new research findings released last night (July 20)  at the International AIDS Society Conference.

In the wake of the study’s findings, South Africa is preparing to offer earlier treatment to people living with HIV.

Conducted among about 1,760 couples in which one partner was HIV positive, the study sought to test whether antiretroviral (ARV) treatment could prevent people living with HIV from transmitting the virus by reducing the amount of HIV in a person’s blood.

Enrolling largely heterosexual couples from nine countries, including South Africa, the study also wanted to answer a decade-old questions: Could earlier HIV treatment be better for people living with HIV?

According to the study’s team of researchers, the answer to both questions is a resounding yes. 

“Antiretrovirals have proven to be the only intervention that really reduces HIV transmission,” says Dr Ian Sanne. CEO of the South African HIV and tuberculosis non-profit the Right to Care, Sanne worked on the study. “(They) are still better than any other prevention intervention undertaken, this includes microbicides, and they are better than condom use.”

While condoms are highly effective in preventing HIV transmission, their inconsistent use by sexual partners diminishes their effect. According to Sanne, many people in the study had difficulty using condoms every time they had sex despite frequently being counselled on how to use them properly.  

Reduced HIV viral load key in reduced risk

The study’s early 2011 results showed a slightly higher reduction in HIV risk among the couples, but the difference is not significant, according to Sanne. However, the eight new infections that occurred between couples in which the HIV-positive partner was on treatment remain a cautionary tale, he says.

“We may have gotten the messaging wrong there,” says Sanne, adding that many of these new infections occurred when partners had just started HIV treatment and before the partner’s HIV viral loads – or the measure of HIV in their blood – had fallen to the low levels needed to reduce the risk of transmitting the virus.

He explains that some participants may have mistakenly believed that treatment alone – instead of the reduced viral load – were sufficient to reduce their infection risk.

According to Sanne, it takes up to three months of adhering to ARVs before viral loads drop to low levels that are often called “undectable.”

Using sophisticated technology, the National Health Laboratory Services (NHLS) tracks the viral load of HIV patients living all over the country.

According to the NHLS’ head of its National Priority Programmes Unit Wendy Stevens, the lab service can pool this data to visually map HIV viral loads at provincial and district levels based on hundreds of thousands of viral loads done monthly.

According to available data, Stevens says about 75 percent of South Africa’s ARV patients have undetectable viral loads but she says this is still short of the targeted 90 percent. 

She adds that provinces like Gauteng have registered real reductions in viral loads among some communities.

“There have been success stories at every level and real changes in communities’ viral loads,” says Stevens, who adds that the data also reveals problem spots nationally and will allow the Department of Health to target areas and even clinics where viral loads remain high. 

South Africa ponders earlier HIV treatment

Sanne’s  study is also at least the third such large-scale study to recently prove that earlier treatment at higher CD4 counts is better for people living with HIV. 

CD4 counts are a measure of the immune system’s strength.

Read: Understanding viral load vs CD4 count

Currently, South Africans must wait until their CD4 counts drop to 500/mm3 or below before starting ART treatment. (The CD4 cell count indicates the state of an individual’s immune system and in an average HIV-male could be anywhere between 400 and 1 600.)

Sanne’s study is the latest to show that ARV treatment above this threshold can benefit HIV-positive people. In May, the START trial found that people starting treatment earlier had a 53 percent reduction in opportunistic infections.

Based on findings like these, the Department of Health Deputy Director General Dr Yogan Pillay has already predicted that the World Health Organisation will recommend people be started on ARVs as soon as they are diagnosed with HIV in a strategy called “test and treat.”

“South Africa is considering the test and treat strategy and, in principle, we will be moving towards test and treat,” Sanne says.

“The idea is that we would require less laboratory monitoring (of CD4 counts) … there would be an overall simplification of the programme to being more people onto treatment quickly.” 


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