From scientific advances to public health implementation
The robust arsenal of antiretroviral drugs and scientifically proven interventions now available to treat and prevent HIV infection offers unprecedented opportunities to make major gains in the fight against HIV/AIDS and ultimately end the pandemic, according to Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health.
Dr. Fauci's remarks were delivered at the XIX International AIDS Conference (AIDS 2012) in Washington, D.C., as part of his opening plenary address, “Ending the HIV/AIDS Pandemic: From Scientific Advances to Public Health Implementation.”
“We are on scientifically solid ground when we say we can end the HIV/AIDS pandemic,” Dr. Fauci said. “The end of AIDS will not be accomplished, however, without a major global commitment to make it happen. We have a historic opportunity — with science on our side — to make the achievement of an AIDS-free generation a reality.”
Globally, more than 34 million people are infected with HIV, including more than 1.1 million people in the United States. The conference venue, Washington, D.C., has one of the highest HIV prevalence rates in the United States, with roughly 2.7 percent of adult and adolescent residents living with HIV or AIDS.
Dr. Fauci noted that extraordinary advances in basic and clinical research in HIV/AIDS have been made over three decades. This understanding has paved the way for evidence-based interventions, including the development of nearly 30 approved antiretroviral drugs to treat people with HIV infection. Used in combination, these medications can dramatically improve an individual's health and longevity.
Despite international programs that have markedly increased global access to antiretroviral therapy, challenges remain, said Dr. Fauci. Nearly half of HIV-infected people living in low- and middle-income countries and eligible for therapy still are not receiving needed antiretrovirals. Only a fraction of the people infected with HIV worldwide, including those living in wealthy countries, can effectively navigate the HIV care process from testing to successful treatment.
“We know that retaining patients in a community-based HIV treatment setting is possible,” said Dr. Fauci, noting that an HIV treatment program in rural Rwanda retained 92 percent of its patients for two years, and nearly all of those patients who had viral load testing had minimal levels of virus after two years. “We need to figure out how to make this work on a much broader scale and in different settings,” Dr. Fauci said.
In addition to their lifesaving role as treatment, antiretrovirals have also played an important role in HIV prevention, augmenting the non-treatment related prevention tools that already exist, thus providing a comprehensive, combination prevention strategy.
“In the United States, we have virtually eliminated mother-to-child HIV transmission through antiretroviral access, but it remains a significant problem globally,” said Dr. Fauci.
Several clinical trials have shown that people at high risk for HIV infection can reduce their risk of acquiring the virus by taking an antiretroviral pill daily — a practice known as preexposure prophylaxis, or PrEP. Antiretrovirals formulated as microbicides for use at the genital mucosa also have shown promise as PrEP. People who most closely adhered to their oral or topical PrEP regimen have experienced the best results, Dr. Fauci noted. The Food and Drug Administration recently approved a pill combining two antiretrovirals for once-daily use as oral PrEP when used as part of a comprehensive HIV prevention strategy. To improve treatment adherence, researchers are working to develop longer-acting antiretrovirals that could be given monthly or even less frequently, such as by injection or topically in vaginal rings.
The preventive effect of antiretroviral therapy has also been demonstrated among serodiscordant heterosexual couples, where one partner is HIV-infected and the other is not, in a strategy known as “treatment as prevention.”
“Antiretroviral treatment helps an infected person stay healthy by controlling his or her level of virus. At the same time, by reducing the level of virus in the infected individual, treatment makes that person less likely to infect his or her sexual partners, thereby preventing HIV infection,” said Dr. Fauci.
Other proven HIV prevention methods include voluntary medical male circumcision, which was shown in clinical trials in Kenya and Uganda to reduce a heterosexual man's risk of acquiring HIV by 50 to 60 percent — an effect that increases over time.
According to Dr. Fauci, HIV prevention interventions found efficacious in clinical trials have shown impressive effectiveness when scaled up and properly implemented in well-defined real-world settings.
Although significant scientific challenges remain in HIV research — notably, developing a vaccine and a cure — results from these real-world settings strongly indicate that global scale-up of existing and scientific evidence-based interventions could dramatically change the trajectory of the HIV/AIDS pandemic and ultimately lead to the end of AIDS, Dr. Fauci said.
“Ending the HIV/AIDS pandemic is an enormous and multifaceted challenge, but we now know it can be done,” said Dr. Fauci. “It will require continued basic and clinical research, and the development and testing of additional treatment and HIV prevention interventions and, importantly, implementing these interventions on a much wider scale.”
Further, this will require a global commitment of countries, governments and communities to strengthen their health care systems and build the capacity to provide HIV treatment and prevention.
“This will require the continued investment of current donors and partners and the addition of new donor organizations and countries,” Dr. Fauci noted. “Lastly, we must enhance what works and eliminate what does not, overcome legal and political barriers, and remove the stigma associated with HIV.”
NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID website at http://www.niaid.nih.gov.
About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.