The big AIDS debate:  Is Prevention or Treatment the catalyst for breaking the back of the HIV/AIDS epidemic in South Africa

10 October 2011

From the left: Prof Geoff Setswe, Head of the School of Health Sciences, Monash South Africa;.Ms Gugu Shongwe, Public Health Specialist, US Centers for Disease Control and Prevention; Dr Henry Fomundam, Public Health Specialist, Howard University, Africa Office.

At the HIV AIDS Debate from the left: Ms Koena Kotsokoane, Coordinator: Monash Africa Centre; Ms Gugu Shongwe, Public Health Specialist, US Centers for Disease Control and Prevention; Dr Henry Fomundam, Public Health Specialist, Howard University, Africa Office; Ass Prof Dina Burger, Deputy Pro Vice-Chancellor: Research, Monash South Africa.

An HIV/AIDS debate: “Is Prevention or Treatment the catalyst for breaking the back of the HIV/AIDS epidemic in South Africa” was hosted by the Monash Africa Centre and Monash South Africa School of Health Sciences at the Monash campus in Johannesburg, on 27 September 2011.

The Prevention Advocate was Ms Gugu Shongwe, Public Health Specialist, US Centers for Disease Control and Prevention (CDC), Global AIDS Programme SA. The Treatment Advocate was Dr Henry Fomundam, Public Health Specialist, Howard University, Africa Office.

The well-attended and lively debate was moderated by Prof Geoffrey Setswe,Professor of Public Health, Monash University Australia and Head of the School of Health Sciences at Monash South Africa.

Dr Fomundam summarised the current situation in South Africa with (2008) data showing that out of a population of about 48.6 million, an estimated 5,700,000 (2007) people are living with AIDS, with a prevalence of 18.1% in the 15-49 age group, and an infection rate of 340,000 adults per year, annual AIDS deaths of 310,000 per year (adults and children), and an estimated 1.9 million orphans due to AIDS. The proportion of HIV-infected population on anti-retroviral treatment (ARVs) was 971,000 out of 2,600,000 in need (or 37%).

The argument for Treatment
Dr Fomundam suggested that in our approaches to reducing the incidence of HIV AIDS we should dare to think and act differently.  

He argued that, because, in most cases sexual intercourse is spontaneous, HIV prevention along the lines of ‘ABC’ (abstinence, behaviours and condoms) becomes very challenging. Despite prevention efforts, driving factors continue to be: multiple and concurrent sexual partnerships; discordance in long-term couples; substance abuse; a low prevalence of male circumcision; low and inconsistent condom use and sub-optimal implementation of HIV prevention interventions within clinical arenas. He said that contributing societal issues include poverty; unemployment; migration; stigma; gender inequality and lack of human rights.

He quoted the example of the Cuban Public Health response to AIDS which included an initial quarantine of all HIV-positive patients, starting with HIV positive soldiers returning from Africa. Quarantine and travel restrictions helped to keep down the epidemic, with Cuba having the lowest HIV rate in the hemisphere (with only 3,200 HIV cases in 2008).  Although the Cuban model of quarantine was very effective, it was also a gross violation of human rights. Fomundam suggested that we rather consider methods to quarantine the virus only.

In January 2008, Swiss HIV experts produced the first-ever consensus statement saying that that HIV-positive individuals on effective antiretroviral therapy, and without sexually transmitted infections, are sexually non-infectious. The statement has been published in the Bulletin of Swiss Medicine.  (He noted that some caveats are that a blood-virus load of less than 50 may not equal a semen-virus load of less than 50, and resistance in blood may not be same as in semen).

He said that studies have shown that the chance of reaching a CD4 count >800 cells/ul after six to seven years of treatment, increases with increased CD4 count at baseline. Fomundam argued that, if deployed effectively, efficiently and early, initiation of treatment will be fundamental to turning the tide of the epidemic.

Fomundam showed that mathematical modeling using South African data suggests that widespread annual HIV testing and starting HIV treatment immediately, could dramatically reduce HIV incidence within 10 years and drive prevalence to less than 1% in 50 years. Estimated HIV/AIDS deaths between 2008 and 2050 would be: 11million deaths with no treatment, 8.7million for treatment with CD4<350, and 3.9million for a ‘test and treat’ programme.

Dr Fomundam suggested that more studies are needed to refine the ‘test and treat’ approach.

The argument for Prevention
Gugu Shongwe looked at the extent to which treatment reduces HIV incidence, the costs, quality of life and sustainability. She argued that a drastic reduction in the incidence of HIV is not only possible, but is imperative.

According to Shongwe, research shows that it is easier to prevent risky behaviours before they start, than to change established behaviours and that prevention strategies also promote personal responsibility. She felt that levels of prevention interventions should cover all groups: from individuals, to couples and sex partners, families and communities and that if we could reduce new infections to zero, it would stop the HIV epidemic.

She argued that the advantages of prevention interventions are that they can be provided at multiple entry points, for multiple populations at clinical and community settings and for those who are HIV positive and HIV negative.

According to the World Health Organisation, globally less than one in five people at high risk of HIV infection have access to proven HIVprevention interventions. New evidence-based prevention tools to reduce HIV incidence are available, such as male circumcision and microbicides.

She referred to research (by Salomon et al 2005) that has shown that a prevention-centered strategy provides greater reductions in HIV incidence (36%) and mortality reductions slightly higher to those of the treatment-centered strategies by 2020.

Shongwe argued that prevention is cost-efficient when compared to treatment. Training costs are lower as training is short and precise. No new infrastructure is required and it can be provided by a variety of service providers anytime, anywhere and high coverage can be achieved easily in a short space of time. In the long term it also saves costs with reduced expenditure, reduced hospital admissions and reduced numbers of orphans.

Prevention interventions also empower individuals, who then contribute to community development by improving social norms and enhancing communication in relationships, resulting in reduced gender-based violence and reduced substance abuse. Prevention also serves as the foundation to continuous care and treatment services.

Shongwe said that the challenges of overly focusing on ART and neglecting prevention are that access to ART can make people feel less vulnerable to the ability to infect others, which may lead to increased high-risk behaviors resulting in more new infections. Without reduced HIV incidence, ART will struggle to cope with the growing numbers of those eligible for treatment.

Poor adherence to ART also leads to drug resistance leading to treatment failure and high mortality. Access to HIV services remains inadequate, and not enough people know their HIV status. ART is complicated and expensive and she suggested that treatment failure also needs to be monitored.

Shongwe concluded that there is a need to scale up evidence-based combined prevention interventions that include ART as prevention, but not as the sole strategy to curb the epidemic.

HIV prevention activities and messages can assist to strengthen personal responsibility and adherence and enhance better patient outcomes. She felt that sustained progress in the global fight against HIV and AIDS will be attained only through a comprehensive, multifaceted response.