Thinking Outside the Same Ol' Box

There is a way we can stop the HIV epidemic in South Africa within 10 years, according to a study published in The Lancet on November 25, 2008. You might think this news would have made banner headlines, but with a presidential election, an economic meltdown, and the holidays dominating the minds and hearts of the country, it didn't get much media play. However, with no vaccine in sight and vaginal microbicides not working, we need to think 'outside the box' about how to stop the spread of HIV. In sub'Saharan Africa alone 20 million are infected, yet 80% don't know it. So it is no surprise that there were 2.7 million newly infected with HIV in 2007. In this Lancet article the authors created a mathematical model to evaluate the effect of testing everyone in South Africa over the age of 15 yearly and initiating treatment immediately for anyone who is seropositive. Starting with the assumption that those with an undetectable viral load have only a 1% chance of transmitting HIV and factoring in adherence, resistance, and various issues, they estimated that within a decade the incidence of HIV would decline 95%. At that rate there would be less than one new infection transmitted per each currently infected patient, and this would stop the epidemic. Just as limiting couples to one child will reduce population growth, an aging HIV population would not be replaced by younger infected individuals. Somewhat parallel to this, Julio Montaner of the Vancouver-based British Columbia Center for Excellence in HIV/AIDS, has calculated that new infections would decrease 70% in British Columbia if treatment was started on all HIV patients when CD4 counts dropped to 350 instead of waiting until 200, which 50% of patients there do. This would help, but it still doesn't treat enough of the HIV-positive population to stop the growth of the virus. The authors, of course, cite many obstacles, such as weak health care systems, lack of personnel, and discrimination issues beyond the basic medical concerns of toxicities and resistance. In addition, the adoption of this plan globally would require a quadrupling of HIV-related spending in the next three years, reaching $50 billion by 2015. Cost savings would start by about 2030, according to the researchers, as the total number of HIV-infected people continued to decrease. They also noted other benefits, including better control of HIV-associated tuberculosis, reduction in the high morbidity and mortality from late diagnosis, and effective prevention of mother-to-child transmission. Perhaps, with studies showing that earlier treatment keeps patients healthier and that the recently infected are responsible for 50% of all HIV transmissions in this country, universal testing and treatment may not be that far outside the box. Bowers is an HIV specialist and is board-certified in family medicine. He is in private practice in New York City. Learn more about Bowers at https://www.danbowersmd.com