The 15th International Conference on AIDS and STIs in Africa (ICASA 2008) held in Dakar in December 2008, demonstrated both the enormous progress and outstanding challenges in the global response to AIDS.

The statistics in sub-Saharan Africa illustrate the problem: it is a region where two-thirds of all people with HIV live, but fewer than one-in-five know they are HIV-positive, and where less than a third who should be on treatment are able to access life-saving antiretroviral therapy (ART). The theme of ICASA, ‘Africa’s Response: Face the Facts’, reflected the urgent need for open-mindedness, transparency and change. Scientific, community, business and political leadership were integrated into the programme, providing delegates with an opportunity to focus on the reality of HIV/AIDS in Africa, to evaluate where there had been successes and shortfalls, and to learn from both.

Here, one of two anti-HIV drugs are taken before sex, either orally, or contained in a gel used for genital lubrication. Studies are currently underway and results will begin to emerge later this year.

Many speakers at AIDS 2008 underscored the need to integrate prevention and treatment interventions to ensure a more effective and sustainable response to HIV/AIDS. This ‘marriage’ of treatment with prevention follows a series of disappointing results in trials for other types of emerging prevention technologies, such as vaccines and microbicides (female-controlled topical HIV-preventative agents) pointing to the need for a more pragmatic way of working to mitigate the epidemic – a multi-pronged approach termed ‘combination prevention.’ The idea is surprisingly simple: focusing on just one method, whether socio-behavioural or biomedical, is unlikely to produce as effective results as combining methods.

The biomedical intervention with the most robust data so far, male circumcision, is a case in point. Three trials undertaken in Kenya, Uganda and South Africa previously found that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60 per cent. Although impressive, since circumcision is not completely effective when used alone as a prevention tool, it is likely to be most effective in combination with condom use and socio-behavioural interventions, such as partner reduction.

As awareness of improvements in HIV treatment and care reaches the people who need it, so demand will grow, and it may well require grass roots advocacy to force national Governments and donors to find solutions to these complex issues

FIRST-LINE TREATMENT
Recognising poor health care infrastructures and a limited availability of drugs, current WHO HIV treatment guidelines for low- and middle-income countries, last updated in 2006, have standardised first and second-line ART regimens, and recommend treatment when people show serious symptoms of HIV infection or when the immune system is close to being severely damaged by HIV (measured by a CD4 cell count at or below 200 cells/mm3). In practice, due to a lack of CD4 cell counting machines in many settings, people tend to be treated only when they show signs of illness. But a study from Mali, presented at ICASA 2008, found that a policy of starting treatment based on clinical symptoms often missed patients with CD4 counts below 200 cells/mm3, resulting in people starting treatment very late, greatly increasing their short-term risk of hospitalisation or death.

Delegates discussed the widening gap in treatment standards – both in terms of when to start and the individual drugs used – between low and middle-income countries, and high-income countries. In the latter, initiation of treatment is now recommended at a higher CD4 count (350 cells/mm3) following evidence from recent trials suggesting that earlier ART initiation may reduce the risk of both AIDS-defining illnesses, and non-AIDS cancers and heart, liver or kidney disease.

There is no doubt that the scale-up of antiretroviral treatment access in Africa has been a remarkable achievement, increasing from 21 per cent coverage in 2006 to 30 per cent coverage in 2007. Delegates at ICASA 2008 discussed the difficulty of establishing guidelines advocating for earlier treatment that will make many millions more eligible for ART when it is already clear that most countries will not meet the goal of universal access by 2010, based on the current, lower thresholds of initiating treatment.

Similarly, high-income countries no longer recommend the anti-HIV drug, stavudine (also known as d4T) as a first-line therapy due to its high rates of toxicity, preferring a newer drug, tenofovir, which is better tolerated, but costs significantly more than d4T or another alternative, AZT, even as a generic, primarily because it is a more complex molecule, requiring more production steps and a larger volume of raw materials than d4T or AZT. continue >>