More must be done to bring the HIV epidemic under control. As the 19th International AIDS Conference approaches in Washington, DC, this July some hard questions must be asked not the least of which is, have all of the public health measures been fully employed to bring the HIV epidemic under control or worse, have some been ignored? Setting goals for controlling the HIV epidemic but failing to utilize all available measures to do so makes no sense.

What needs to be done now?

1Treat all HIV infected women, children and men regardless of clinical status or CD4 count.

2.  Simplify prevention and treatment guidelines to facilitate their implementation by all levels of health care workers.

3. Contact tracing should be implemented to identify all those who are HIV infected and to treat all.

4. Integrate health care services to deliver more health for the same cost.

5.  Train all rural and community health care workers to bring HIV prevention and care equally to rural and urban regions.

A major concern is whether the most recent WHO guidelines ignored results of clinical research studies that caused other international organizations to revise their guidelines to recommend treating all HIV infected individuals regardless of CD4 counts.1-3 Clinical research indicates that starting ART earlier than recommended by WHO could significantly reduce the continued long term human and economic cost of the epidemic.2, 4, 5 In failing to revise their guidelines WHO is out of step with other standard of care recommendations that take into account the broad benefits of early ART in reducing mortality, morbidity, opportunistic infections including tuberculosis, decreasing HIV transmission (treatment as prevention), decreasing non HIV-related diseases, decreasing hospitalization costs, maintaining CD4 counts, and, preserving the life of HIV infected care givers potentially reducing the vast HIV related orphan epidemic.2-4, 6-9 It is not unreasonable to question whether the 2010 WHO guidelines can be interpreted as limiting the number of HIV infected patients gaining access to beneficial treatment rather than maximizing the number of HIV infected individuals who could who would benefit from early highly active combinations (HAART).

Accepting that there is a major public health benefit to increasing the number of HIV infected patients who are placed on early ART then a priority should be that we must identify the millions of HIV infected individuals who are unaware of their infection rather than waiting until they present with advanced disease. Contact tracing could accomplish this but it is as if contact tracing has been expunged from the public health vocabulary for controlling the HIV epidemic. Of over 50 medical articles published since 2005 on HIV prevention and treatment, only two offered contact tracing as a solution to controlling HIV transmission (References available on request.)

Few epidemics have escaped the need for contact tracing. Early in the HIV epidemic there were valid reasons for delaying the use of contact tracing. Unacceptable levels of stigma and discrimination were directed at HIV-infected individuals. Prior to 1987 before ART was available, it was argued that without treatment, contact tracing would not benefit HIV infected individuals, an argument which unfortunately failed to take into account the potential for preventing new HIV infections and opportunistic infections through education, contact tracing and antibiotic prophylaxis.  The subsequent development of large numbers of highly active antiretroviral drugs, community activism, and the development of specific laws to protect HIV-infected individuals overcame these arguments. One which lingered however was that divulging one’s HIV status would result in violence against women. Recent studies report that women who are HIV-infected are more likely to suffer from intimate partner violence (IPV) and that HIV may be yet another manifestation of IPV, albeit a potentially fatal one.10, 11 Additional studies concluded that when community and social support is provided for women who divulge their HIV status, the level of discrimination and abuse is diminished.12

Failing to perform contact tracing results in ongoing transmission of HIV to uninfected sexual partners and in the case of pregnant women, uninfected infants.  But it also delays the benefits of early lifesaving HAART. In effect, without contact tracing, millions of individuals are denied their right to remain HIV uninfected or if already infected, their right access to lifesaving treatment early in infection when HAART has the greatest potential for preserving health.

Acknowledging that funding for HIV is decreasing, it is essential that greater efficiency of health care delivery be accomplished. It makes little sense to require independent resources and training limited to HIV prevention and care when individuals and entire communities require integrated approaches to malaria, tuberculosis, malnutrition, violence against women and suffer high rates of maternal and infant mortality.

The shortage of trained health care and community workers contributes to the persistence of the HIV epidemic in regions which may be the source of continued spread of HIV.Focusing on controlling the HIV epidemic in urban areas while neglecting rural regions where over 50% of the world’s population resides will result in on ongoing HIV epidemic as individuals migrate within their own and across country borders.

At a time when the HIV global health community is calling for greater prevention efforts and for more individuals to be HIV tested and placed on treatment, a major public health mechanism for early identification of infected individuals or those at risk of infection cannot be abandoned.  Behavior change, use of condoms, male circumcision, prevention of mother to child HIV transmission utilizing HAART and most recently, treatment of HIV infection to reduce transmission to sexual partners have all impacted the HIV epidemic. If we are to make further strides in controlling the HIV epidemic then all individuals who have been exposed to, or who are already infected with HIV, should know their HIV status. Estimates are that there are over 100,000 individuals in the US who do not know that they are infected with HIV – worldwide the number is estimated to be in the millions. It is unlikely that further control of the HIV epidemic can be achieved without placing all HIV infected patients on HAART regardless of CD4 counts, or as some have argued, provide HAART universally.13 Public health policy and guidelines from influential organizations such as the WHO should recommend the highest standard of care such as recently recommended by the US Public Health Service  and maximal utilization of tools, such as contact tracing, for controlling an infectious disease epidemic that has gone on for much too long.

References

  1. Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a public health approach 2010 revision. http://www.who.int/hiv/pub/arv/adult2010/en/index.html (Accessed March 1, 2012)
  2. Thompson MA, Aberg JA, Cahn P, et al. Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel. Jama 2010;304:321-33.
  3.  Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and
  4. Human Services. October 14, 2011; 1–167. 2011. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf (Accessed March 1, 2012)
  5. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009;360:1815-26.
  6.  Hammer SM, Eron JJ, Jr., Reiss P, et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel. Jama 2008;300:555-70.
  7. Moore RD, Keruly JC. CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression. Clin Infect Dis 2007;44:441-6.
  8. Sterne JA, May M, Costagliola D, et al. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet 2009;373:1352-63.
  9. Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med 2010;363:257-65.
  10. Neuhaus J, Angus B, Kowalska JD, et al. Risk of all-cause mortality associated with nonfatal AIDS and serious non-AIDS events among adults infected with HIV. Aids 2010;24:697-706.
  11. Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc 2010;13:6.
  12. Jewkes RK, Levin JB, Penn-Kekana LA. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med 2003;56:125-34.
  13. Brown LB, Miller WC, Kamanga G, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention. J Acquir Immune Defic Syndr 2011;56:437-42.
  14. Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009;373:48-57.