HIV/AIDS

Global Leaders Slow to Promote HIV ‘Treatment-as-Prevention’ in Sub-Saharan Africa

A new perspective paper led by Jacob Bor, assistant professor of global health and epidemiology, zeroes in on policymakers’ failure to disseminate conclusive evidence that HIV medicine prevents sexual transmission of the virus.

Ten years after the landmark HIV Prevention Trials Network 052 trial (HPTN 052) concluded that antiretroviral therapy (ART) prevents the sexual transmission of HIV through viral suppression, significant global disparities persist in knowledge about the efficacy of this “treatment as prevention” (TasP), according to a new perspective paper co-authored by a School of Public Health researcher and published in the New England Journal of Medicine.

The paper argues that global and national policymakers have failed to disseminate established research and messaging on the clinical and public health benefits of TasP to the public, and that this lack of clear and widespread communication may limit the impact of HIV treatment policy on population health.

“Treating HIV is among the most effective ways to prevent transmission,” write lead author Jacob Bor, assistant professor of global health and epidemiology, with senior author Kenneth Mayer, medical research director and co-chair of The Fenway Institute; and co-authors Dorina Onoya, principal researcher in the Health Economics and Epidemiology Research Office at the University of Witwatersrand in Johannesburg, South Africa; and Bruce Richman, founding executive director of the Prevention Access Campaign. “Yet in many countries, TasP isn’t broadly emphasized in public health information campaigns, HIV-education curricula, or HIV counseling.”

HPTN 052, along with several subsequent large-cohort studies, found zero risk of HIV transmission between mixed-status couples in which the HIV-positive partner was on ART and virally suppressed. This breakthrough fueled extensive global policy changes that placed treatment at the center of HIV prevention, the authors write, with countries worldwide implementing HIV “test-and-treat” policies designed to reduce transmission. Still, policy-makers have failed to inform the public of the rationale for these policies. Existing evidence from sub-Saharan Africa – including work by Bor and colleagues recently published in the journals Sexually Transmitted Infections and AIDS & Behavior – indicate large knowledge gaps.

The “Undetectable equals Untransmittable” (U=U) educational campaign, founded by co-author Bruce Richman, promotes TasP and the science-based evidence that people with HIV who are on treatment and have an undetectable viral load cannot transmit HIV. A growing number of countries have embraced the U=U message.

“Sharing information on TasP and U=U is important not only from an ethical standpoint; there is growing evidence that it’s good clinical and public health practice,” the authors write, pointing to previous research that found significant improvements in treatment adherence and viral suppression when TasP information about TasP was incorporated into counseling interventions. “In the second decade of TasP, we believe it’s essential to ensure that the science is disseminated to all who stand to benefit.” Read the full perspective paper, and listen to an interview with the author, here.