New treatment strategy could greatly reduce HIV

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Aug. 10 2006 A provocative new strategy for tackling HIV could reduce the global prevalence of the virus seventy-fold, according to a Canadian doctor who designed the theory.

The strategy would revolve around the use of highly active antiretroviral therapy, or HAART -- a treatment for human immunodeficiency virus (HIV) infection that uses a combination of several antiretroviral drugs.

While HAART has traditionally been used to extend the lives of HIV patients, the new theory states that expanding HAART therapy can result in greatly reduced transmission rates among those who carry the virus.

HAART reduces viral loads of HIV in the patient's blood until it is undetectable, and as a result they become less infectious.

However, less than 30 per cent of the people in the world who qualify for antiretroviral drugs are taking them, and more than 70 per cent are not. These are the people who are fueling the growth of the epidemic, said CTV's medical specialist Avis Favaro.

Lead author of the study, Dr. Julio Montaner, explained his theory using the analogy of paying off a mortgage.

"The greater your down payment, the sooner your mortgage extinguishes," Montaner told Canada AM Friday.

"We're looking at treatment here in the same way."

According to Montaner's theory, the sooner you put people in treatment, the greater the reduction of HIV transmission.

"You could have a very dramatic effect on the epidemic to the point this epidemic could extinguish itself," he said.

According to a population model created by the B.C. Centre for Excellence in HIV/AIDS, widespread use of the program over 45 years could result in a reduction of the current rate of more than seven cases of HIV per 1,000 people, to 0.1 cases for the same number of people.

That would reduce the total number of HIV infected people from 40 million to less than one million.

The theory was published in an article in the international medical journal The Lancet, in a special edition focusing on HIV and AIDS. The article was prepared by the Centre under Montaner's direction.

B.C.'s provincial health officer, Dr. Perry Kendall, told CTV he believes in Montaner's work.

"The strategy that Dr. Montaner is proposing is of critical importance because a major issue of the HIV epidemic is stopping the transmission person to person, and we obviously have not been entirely successful in doing that in North America and we have been far from successful in doing that in sub-Saharan Africa and the developing world," Perry said.

The use of HAART has brought dramatic results in regions where the results have been recorded. Data from B.C. and Taiwan shows a whopping reduction of about 50 per cent in new HIV cases as the result of free access to the program.

Those numbers would have translated to about 40,000 new cases in North America last year, and the cost of treating those patients with HAART would have added up to about $10 billion US.

"Data that we've gathered at the B.C. center and elsewhere indicates that widespread use of HIV medicines has had an affect on decreasing transmission of HIV virus," Montaner, the director of the centre told CTV News.

"At the end of the day we have come up with the hypothesis that says that enhanced users of antiretroviral therapy, which is a treatment for HIV, may actually contribute to curbing the growth of the epidemic."

Not only would the expansion of the program reduce the number of cases of HIV, but it would also make the HAART program itself much more cost effective in the long run, Montaner and his colleagues maintain.

The model demonstrated that the cost of treating all the world's HIV infected people ($15 billion US) today would be more than offset by the of new cases that could be prevented by the program.

The special edition of The Lancet was published to coincide with the 16th International AIDS Conference in Toronto on Aug. 13-18. The event is advertised as the largest HIV/AIDS conference in the world, and the speakers include the UN Special Envoy for AIDS/HIV in Africa Stephen Lewis, former U.S. president Bill Clinton, Bill and Melinda Gates and actor Richard Gere.

Montaner will present the theory on Aug. 16 at the conference.

"It's time that we start talking about it, and the Center would like to lead that discussion because if that is the case between better prevention and strengthening of our treatment programs we may be able to, at least in the short term, control the spread of HIV."

The article written by Montaner and his colleagues for The Lancet, encourages the expansion of HAART programs internationally until it becomes a cornerstone of the global medical community's HIV prevention strategy.

"We must stress that we do not see HAART as a replacement for the prevention effort -- including vaccine research -- but rather as an essential part of it," said Montaner, who is poised to become president-elect of the International AIDS Society when the conference concludes.

Others agree, the benefits could be broad.

"Dr. Montaner's study is very interesting," Dr. David Marsh, Regional Medical Director for Addiction Services in Vancouver told CTV.

"The suggestion is that by getting people onto a very effective treatment, those who need treatment, we suppress the virus in their body and so not only help them but you prevent the virus from spreading to other people so you get a public health benefit from effective treatment."

But, pointed out Dr. Neil Rau, an infectious disease expert, it's still just a theory and there are hurdles that will need to be overcome.

"It is a very provocative idea, which is very resource intensive. But if the logistics can be overcome, it would certainly be a new approach to addressing new numbers of HIV positive infection and slowing the pandemic."

One of the major obstacles, particularly in the developing world, will be convincing patients who don't want treatment until it is medically necessary, to take medicine for reasons other than their own immediate benefit, Dr. Rau said.

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