I'm writing this from Vancouver where the 2013 Treatment as Prevention Workshop is taking place.
The past few days have certainly confirmed to us all that work around TasP is moving quickly, now that we have the knowledge that starting anti-retroviral treatment early after being infected decreases infectiousness by up to 96%. Only two weeks ago I was in Paris for a country consultation looking at the challenges facing the implementation of TasP in France, following a first-ever consultation of the same type organized with our Zambian colleagues in mid-March.
The consultations have proved to be enlightening and I strongly believe that the successful implementation of TasP will ultimately turn on us identifying the key barriers that exist specific to each country and then pooling that knowledge to determine if we can draw upon those lessons learnt and apply them on a broader level.
What was abundantly clear from the French consultation is that the number one issue in France is to reduce the number of HIV- positive people not knowing they have HIV - estimated to become 20% of the total number of infected people, and then to further improve their access to care and treatment, and finally to maintain an undetectable viral load for as long as possible. This effort can be expected to reduce the delay between infection and screening and needs to take account of the disparities between different groups of population. Today in France, there is strong evidence indicating that there are still delays of up to 60 months amongst certain groups from initial infection to the initiation of treatment!
The success of TasP in France will be highly dependent on screening and its success will be very much linked with reducing the size of the so-called "hidden epidemic" in France - the number of people unaware of their HIV-positive status. Universally that is the responsibility of all stakeholders engaged in fighting AIDS and it is so key to the effective rollout of TasP in most countries.
We see an extra set of challenges in countries like Zambia.
In 2004, only 3,500 Zambians were on ART. By the end of 2012 that number increased to nearly 500,000 people, with an ART coverage of more than 80% of those who require treatment under WHO guidelines of a CD4 count under 350. This has enabled Zambia to reduce the number of new infections by 58%, two years ahead of the global target. This is saving lives. But, despite these successes, only 15% of the country's 13 million people, 1 million of whom are estimated to be living with HIV, have been tested for HIV and know their HIV status.
Therehas been recognition by authorities that many of the bottle-necks in the treatment and care system have been to date inadequate and it is truly encouraging to now see that new Zambian and international guidelines are shifting toward initiating treatment at higher CD4 counts for a greater number of HIV+ individuals. Zambia is on an enlightened path in its treatment strategy. This presents an opportunity for curbing the epidemic effectively.
However, it also poses challenges for Zambian financial, infrastructure, and human resources. While the uniform expansion of testing and treatment is vital to overcoming the HIV epidemic, TasP requires a profound re-thinking of treatment programmes. It also demands an analysis of how healthsystems will cope, considering the implications on funding and expansion of services.
Here in Vancouver this week, under the leadership of Professor. Julio Montaner, we have been privileged to discuss the opportunities and challenges of early access to treatment from all its perspectives based on the latest scientific knowledge.
PEPFAR and UNAIDS leaders Eric Goosby and Michel Sidibé have committed this week to facilitating improved information on early access to treatment and to advocating for a better use of greater resources.
Implementation of TasP strategies has been at the heart of all presentations and conversations here. There is a clear understanding that the individual benefits of early treatment initiation should be balanced with public health benefits when making political decisions on early treatment. TasP will only be an efficient strategy IF:
• stigma is overcome;
• individuals feel free to choose and not be obliged to start treatment;
• people are aware of early treatments' benefits for their individual health on top of its benefits in protecting their partners;
• being on treatment is not associated with "nearing the grave", as a Kenyan HIV-positive woman said in a study presented at the workshop.
The sound implementation of TasP strategies will need to be based on healthy discussions around all the attached legal, economical, and above all, individual and behavioral aspects. . The IAS is playing its part in this process by convening an international working group on these aspects of TasP, as well as organizing country consultations. We are fortunate that, as a co-organiser of the Vancouver workshop, IAS is able to report back from these consultations and add to the comprehensive effort being made here to strive for a balance between the need to comprehensively assess knowledge of all the risks and benefits of TasP implementation against the very real and obvious emergency of saving lives.
Things are moving quickly - not quickly enough, some would argue. But if we look back at the state of discussions only two years ago, when TasP was still only a theory and consider the desire of a diversity of stakeholders taking part in the debates today to take action, we have indeed come a long way in a very short period of time.
I think all of us are confident that we will continue moving towards the implementation of highly effective early access to treatment at the same speed, if we manage to keep the right balance between a public health approach and the benefits to the individual... Sharing information at all levels will be key - namely because, as I opened by saying at the beginning of this blog - overcoming stigma and discrimination will be the ultimate way forward.