Sudahkah kamu Test HIV?

http://www.odhaberhaksehat.org/2013/sudahkah-kamu-test-hiv/
by ayu

“waduh.. kemarin gw habis ML sama pacar lupa pakai kondom. gimanaya..” kata Budi pada sahabatnya “emangnya setiap ML gak pakai kondom gitu?” sahabat balik bertanya

“yah..enggak pernah. gw pengen ajak pasangan cek HIV deh.. gimana caranya ya?“  dengan wajah bingung budi kembali bertanya “nih, baca artikel dibawah ini yuk..”

Apa sih Test HIV Itu?

Tes HIV memberi tahu kita apakah kita terinfeksi HIV, virus penyebab AIDS. Kebanyakan tes ini mencari antibodi terhadap HIV. Antibodi adalah protein yang dibuat oleh sistem kekebalan tubuhuntuk menyerang kuman tertentu. Antibodi terhadap semua kuman berbeda, jadi bila ditemukan antibodi terhadap HIV dalam darah kita, artinya kita terinfeksi HIV. Ada juga jenis tes lain yang mencari tanda bahwa virus sendiri ada di dalam darah, tetapi tes macam ini belum tersedia di Indonesia.

Bagaimana Proses Tes HIV?

Tes yang paling lazim untuk HIV adalah tes darah. Sekarang juga ada tes yang dapat mencari antibodi dalam air seni, atau dalam cairan yang diambil dari dalam mulut (bukan air liur), digesekkan dari dalam pipi. Tes yang sering dipakai sekarang disebut tes cepat atau rapid test, yang mampu menyediakan hasil dalam 20-30 menit setelah contoh darah atau cairan lain diambil. Untuk tes darah, contoh darah kita diambil dengan jarum suntik sekali pakai, atau tetes darah diambil setelah jari kita ditusuk dengan jarum sekali pakai. Jika hasil tes pertama ‘reaktif’ (positif), hal ini menunjukkan kemungkinan kita terinfeksi HIV. Tetapi tes harus diulang sekali (jika kita mempunyai gejala penyakit HIV) atau dua kali dengan cara berbeda untuk memastikan hasilnya benar, dan dapat dinyatakan ‘positif’. Ini biasanya dilakukan oleh tempat tes tanpa kita diketahui. Hasil juga dapat dilaporkan sebagai ‘non-reaktif’ (negatif). Kadang laboratorium juga melaporkan angka non-reaktif (mis. non-reaktif, 0,34).  Angka ini tidak ada relevansi sama sekali dan sebaiknya diabaikan. Sebelum darah diambil, kita wajib diberi konseling oleh seorang konselor yang terlatih. Di antara yang lain, konseling ini akan memberi informasi dasar tentang HIV dan AIDS. Bgmn Manfaat dan kerugian kita mengetahui apakah kita terinfeksi, dan bagaimana kita akan bereaksi jika nanti hasilnya positif Setelah itu, kita diminta menyetujui sebelum darah diambil (sering disebut informed consent). Kita juga wajib diberi konseling lagi oleh konselor yang sama saat hasilnya sudah ada. Hasilnya hanya boleh diberikan pada kita, dan tidak boleh diberikan pada orang lain tanpa persetujuan kita. Tempat melaksanakan tes bertanggung jawab untuk menjamin nama kita dan hasil tes tidak diketahui orang lain. Namun, jika kita di bawah umur, orang tua atau wali kita boleh mewakili kita. Sayangnya, di Indonesia, tidak jelas berapa sebenarnya usia ‘di bawah umur’. Hasil tes tidak wajib dilaporkan ke pemerintah. Ada beberapa tempat tes yang tidak mewajibkan kita memberi nama atau identifikasi. Ini disebut tes tanpa nama atau anonim.

Bagaimana Kita Dapat Dites?

Semua rumah sakit rujukan AIDS (hampir 200 di seluruh Indonesia) dan satelitnya menyediakan layanan tes HIV. Sering kali di klinik disebut VCT (voluntary counseling and testing). Daftar rumah sakit rujukan dapat dilihat di banyak situs situswww.spiritia.or.id atau www.aidsindonesia.or.idSelain itu ada beberapa klinik lain yang menyediakan tes HIV, dan tes juga dapat dilakukan di beberapa laboratorium swasta. walau sering kali lab swasta tersebut tidak menyediakan konseling, pastikan kita mendapat informasinya. Tes HIV di RS kadang disediakan tanpa biaya, tetapi biasa harganya sesuai dgn kebijakan RS.

Siapa Sebaiknya Dites? Kita dapat terinfeksi HIV tanpa mengetahuinya. Kita mungkin tidak merasa sakit atau mempunyai keluhan. Tetapi kita tetap bisa menularkan orang lain. Siapa pun yang aktif secara seksual atau memakai jarum suntik secara bergantian sebaiknya tes HIV secara berkala.

Kapan Sebaiknya Kita Dites?

Jika kita menjadi terinfeksi HIV, biasanya sistem kekebalan tubuh baru membentuk antibodi tiga minggu hingga tiga bulan setelah kita terpajan. Masa ini disebut masa jendela. Jadi, jika kita merasa kita terpajan, atau melakukan perilaku berisiko tertular HIV, kita sebaiknya menunggu tiga bulan setelah peristiwa berisiko sebelum kita dites. Kita juga dapat langsung tes, dan mengulangi tes tiga bulan setelah peristiwa (bukan setelah tes pertama). Selama masa jendela ini, tes antibodi akan menunjukkan hasil non-reaktif (negatif), tetapi walaupun begitu, jika kita sudah terinfeksi kita dapat menularkan orang lain.Sebetulnya, selama masa awal infeksi ini, daya menular kita paling tinggi sehingga kita lebih mungkin menularkan orang lain kalau kita berperilaku berisiko. Menurut pedoman Kemenkes RI, hasil tes HIV yang non-reaktif tiga bulan atau lebih setelah peristiwa berisiko berarti kita tidak terinfeksi HIV, atau dalam kata lain, kita HIV-negatif.

Ada Tes yang Memberi Hasil Lebih Cepat? Tes viral load mencari potongan genetik HIV. Bibit ini terbentuk sebelum sistem kekebalan tubuh membentuk antibodi. Tes viral load tidak biasa dipakai untuk menentukan apakah seseorang terinfeksi, karena tes tersebut jauh lebih mahal dibandingkan tes antibodi. Selain itu, tingkat hasil yang salah lebih tinggi, sehingga tes viral load ini tidak disetujui oleh Kemenkes sebagai alat diagnosis HIV untuk orang dewasa di Indonesia.

Apa Artinya Jika Kita Positif?

Hasil positif atau reaktif berarti kita mempunyai antibodi terhadap HIV, dan itu berarti kita terinfeksi HIV. Hasil tes seharusnya disampaikan kepada kita oleh konselor, yang akan memberi tahu kita apa dampak pada kehidupan kita, dan bagaimana kita dapat memperoleh layanan dan dukungan kesehatan serta emosional. Hasil positif bukan berarti kita AIDS. Banyak orang yang positif tetap sehat untuk beberapa tahun, dan tidak tentu langsung perlu memakai obat apa pun. Penerimaan diagnosis HIV sering kali sangat sulit. Namun kita tidak sendiri, dan bertemu dengan teman senasib dapat sangat membantu pada saat itu. Di beberapa daerah, teman-teman Odha sudah membentuk kelompok dukungan sebaya (KDS) untuk memudahkan proses ini. Minta dirujuk pada KDS terdekat oleh petugas klinik VCT. Atau kami juga bisa menjadi sahabat kalian saat kalian mengetahui status HIV.

Apakah Kita Dapat Mempercayai Hasil Tes?

Hasil tes antibodi untuk HIV adalah benar untuk lebih dari 99,5% tes. Sebelum kita diberi hasil positif, tes diulang sebagai konfirmasi. Ada beberapa keadaan khusus yang dapat memberi hasil yang salah atau tidak jelas. Bayi yang dilahirkan oleh ibu yang HIV-positif dapat menunjukkan hasil positif untuk beberapa bulan karena antibodi ibu dialihkan ke bayi yang baru lahir. Walaupun bayi sebenarnya tidak terinfeksi, dia mempunyai antibodi terhadap HIV dan hasil tes dapat reaktif sampai dia berusia 18 bulan. Tes lain, misalnya tes viral load, harus dipakai jika hasil yang benar dibutuhkan lebih cepat. Orang yang baru terinfeksi dapat menunjukkan hasil negatif (non-reaktif) jika dia dites terlalu dini (dalam masa jendela) sejak terinfeksi dengan HIV. Ibu hamil mungkin menunjukkan hasil palsu atau tidak jelas akibat perubahan pada sistem kekebalan tubuhnya.

Tes HIV biasanya mencari antibodi terhadap HIV dalam darah atau cairan tubuh lain. Bila kita terinfeksi HIV, sistem kekebalan tubuh kita membuat antibodi ini untuk melawan HIV. Biasanya dibutuhkan tiga minggu hingga tiga bulan untuk membentuk antibodi tersebut. Selama masa jendela ini, tes kita tidak akan menunjukkan hasil positif walaupun kita terinfeksi. Tes HIV biasa juga tidak memberi hasil yang benar untuk bayi yang baru lahir pada ibu yang terinfeksi HIV. Hasil tes yang positif (reaktif) berarti kita terinfeksi HIV, tetapi tidak berarti kita AIDS. Jika kita memang HIV-positif, sebaiknya kita belajar tentang HIV, dan mempertimbangkan bagaimana kita dapat melindungi kesehatan kita. Sudahkah kamu cek HIV?

Prevention Benefits of HIV Treatment

http://www.cdc.gov/hiv/prevention/research/tap/index.html

Summary

To realize the full prevention benefit of treating HIV infection, we should keep in mind four overarching tenets:

• HIV testing is the foundation for both prevention and care efforts.
• Early identification of infection empowers individuals to take action that benefits both their own health and the public health.
• Early treatment of infected persons substantially reduces their risk of transmitting HIV to others.
• The prevention benefit of treatment can only be realized with effective treatment, which requires linkage to and retention in care, and adherence to antiretroviral therapy.

• Introduction

  The advent in 1996 of potent combination antiretroviral therapy (ART), sometimes called HAART (highly active antiretroviral therapy) or cART (effective combination antiretroviral therapy), changed the course of the HIV epidemic.¹ These “cocktails” of three or more antiretroviral drugs used in combination gave patients and scientists new hope for fighting the epidemic,² and have significantly improved life expectancy—to decades rather than months.^1,3
  For many years, scientists believed that treating HIV-infected persons also significantly reduced their risk of transmitting the infection to sexual and drug-using partners who did not have the virus. The circumstantial evidence was substantial, but no one had conducted a randomized clinical trial— the gold standard for proving an intervention works. That changed in 2011 with the publication of findings from the HIV Prevention Trials Network (HPTN) 052 study, a randomized clinical trial designed in part to evaluate whether the early initiation of ART can prevent the sexual transmission of HIV among heterosexual couples in which one partner is HIV-infected and the other is not. This landmark study validated that early HIV treatment has a profound prevention benefit: results showed that the risk of transmitting HIV to an uninfected partner was reduced by 96%.⁴
  As a concept and a strategy, treating HIV-infected persons to improve their health and to reduce the risk of onward transmission—sometimes called treatment as prevention— refers to the personal and public health benefits of using ART to continuously suppress HIV viral load in the blood and genital fluids, which decreases the risk of transmitting the virus to others. The practice has been used since the mid- 1990s to prevent mother-to-child, or perinatal, transmission of the virus. Research published in 1994 showed that zidovudine, more commonly known as AZT, when given to HIV-infected pregnant women and to their newborns reduced the risk of perinatal transmission from about 25% to 8%⁵. Since then, routinely testing pregnant women and treating infected mothers with ART during pregnancy, delivery, and while breastfeeding, when practiced according to recommendations, has reduced the mother’s risk of transmitting HIV to her child by 90%.⁶  In one study, women who received at least 14 days of ART reduced the risk of transmitting HIV to their babies to less than 1%.⁷

  Putting Treatment as Prevention in Perspective

  Treatment by itself is not going to solve the global HIV epidemic. On the domestic front, controlling and ultimately ending the epidemic will require a combination of scientifically proven HIV prevention tools as highlighted in the National HIV/AIDS Strategy, including
  • Focusing on science-based HIV prevention efforts by supporting and expanding targeted use of high-impact HIV prevention approaches.
  • Making better investments by intensifying HIV prevention in the communities where HIV is most heavily concentrated.
  • Increasing access to HIV screening and medical care, including through
    • boosting federal investments for AIDS Drug Assistance Programs (ADAPs) to expand access to life-saving medications, and
    • implementing the Affordable Care Act, which will increase health coverage for thousands of Americans living with HIV.
  • Sustaining a shared response to the domestic epidemic through the support of HIV prevention efforts across all levels of society, including federal, state, and local governments, faith-based communities, and the private sector.
  Providing treatment to people living with HIV infection to improve their health must always be the first priority. Getting an HIV test is the first step to identifying persons with HIV infection and the pivotal entry point into the medical care system for both treatment and prevention. More than 1.1 million persons in the United States are living with HIV, and almost 1 in 5 (18.1%) do not know they are infected.⁸ By lowering the level of virus in the body, early ART helps people with HIV live longer, healthier lives and also lowers their chances of transmitting HIV to others. Although observational data had suggested that ART significantly reduces viral load and the risk of sexual transmission of HIV in heterosexual couples where one partner is infected and the other is not,^9,10 it was the HPTN 052 study that definitively showed that early treatment of HIV-infected persons dramatically cuts the rate of new infections. Studies of communities with high concentrations of injection drug users (IDUs) and men who have sex with men (MSM) have shown that as ART use increased within the community, the community’s viral load declined, as did rates of new HIV diagnoses.^11,12However, it is critical to remember that the prevention benefit of treatment is not 100%, and there has been at least one report of HIV transmission from a person with suppressed viral load to an uninfected sexual partner.¹³ 
  
  For persons living with or at risk for HIV infection, emphasizing these fundamental safeguards will continue to be crucial:
  • Knowing their HIV status through routine testing.
  • Getting into care soon after HIV diagnosis and starting antiretroviral treatment.
  • Remaining in care and staying on HIV treatment.
  • Modifying behaviors that reduce the probability of getting or spreading HIV—such as using condoms properly and consistently, reducing numbers of partners, and avoiding sharing needles and syringes.

  Test and Treat

  The ability of antiretroviral drugs to prevent secondary transmission of HIV from an infected person to an uninfected sexual or drug-using partner has led to several proposed “test-and-treat” strategies. Test-and-treat programs are based on the premise that the rate of new HIV infections will be maximally reduced by using aggressive methods to test and diagnose all people living with HIV infection, treat them with ART regardless of CD4 cell count or viral load at diagnosis, and link them to care. In one study, mathematical modeling suggested that a universal test-and-treat-strategy in which all adults aged 15 years or older are tested annually could control the South African epidemic, reducing both HIV incidence and mortality to less than 1 case per 1,000 people per year within 10 years of full implementation of the strategy—and reducing prevalence of HIV infection to less than 1% within 50 years.¹⁴ Other investigators have not been as optimistic about the ultimate benefits of this strategy. Only 50% of persons in the United States with HIV remain in care,^15,16 and about 18% do not know they are infected; these persons may contribute to the onward transmission of HIV. In addition to expanding testing and treating HIV infection earlier, overcoming the challenges of undiagnosed infection and poor engagement in care will result in better care of HIV-infected populations and reduced numbers of new HIV infections.^{17, 18}

  Challenges and the Future of HIV Prevention

  The landmark HPTN 052 clinical trial was conducted almost solely among heterosexual couples who, as part of the study, received frequent counseling related to HIV, sexually transmitted diseases (STDs), and family planning. Results of a recent observational study of more than 38,000 serodiscordant heterosexual couples across China showed that treating the HIV-infected partner reduced the risk of transmitting HIV to the uninfected partner by 26%—a much more modest effect than that found in the HPTN 052 study couples. Unlike the couples enrolled in HPTN 052, the couples in China were not part of an intensive study, and data were not available on sexual risk factors, adherence to antiretroviral treatment, or virological treatment outcome measures.¹⁹ Additional data are needed to estimate the prevention benefit of treatment for other populations, such as MSM, IDUs, and persons with acute or primary HIV infection,²⁰ and in other settings such as North America and during routine clinical care.
  As HIV treatment has evolved from a complicated regimen of numerous pills taken several times a day with severe side effects to a now once-daily pill with few side effects, some persons living with HIV may have become complacent about maintaining safer sex and safer injection use practices. Since HIV treatment became widely available in developed countries, several studies have shown a resurgence of HIV infections and increases in STDs, in particular syphilis, and especially among MSM.²¹ Some studies have cautioned that the prevention benefits of effective ART would be offset by risk compensation, meaning that increases in risky sexual and injection-drug-use behavior might be observed as effective ART is widely disseminated.^22-24 However, results of one meta-analysis demonstrated that HIV-positive persons receiving ART, compared with those not receiving ART, did not show increased sexual risk behavior, even when therapy resulted in an undetectable viral load.²⁵ Yet, persons with HIV who believe that using ART or having a suppressed viral load protects them against transmitting HIV may be more likely to engage in unprotected sex or other risky behaviors. These behaviors might be amenable to change through prevention messages and other effective approaches.^25-28 Making sure that preventive behaviors are sustained in communities facing higher risk of HIV infection is crucial.²⁹
  The future of HIV prevention will be shaped by operational and implementation research on the efficacy of combination prevention strategies, of which treatment may be one component.^30-32 Providing treatment to all HIV-infected persons will be an important step—a recommendation that is included in the current Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.³³ The Department of Health and Human Services panel based its recommendations primarily on mounting evidence showing the harmful impact of ongoing HIV replication on AIDS and non-AIDS disease progression. In addition, the updated recommendations reflect emerging data showing the benefit of effective ART in preventing secondary transmission of HIV. Although the panel agrees that this public health benefit of ART is significant, its recommendations on when to begin ART are based primarily on the benefit of treatment to the HIV-infected individual.³³ If treatment is to achieve its full prevention potential, current gaps in the HIV prevention, treatment, and care continuum must be narrowed or closed. Considerable changes in the US health care delivery system will be required to accommodate the increased demand for services that expanded testing, treatment, and linkage and retention in care will bring.³⁴
  Now that early ART of HIV-infected persons has been shown to be very effective at preventing secondary transmission of HIV among individuals, the current goal is to determine the extent to which ART can be used broadly and effectively to reduce the spread of HIV within a population. At least two community randomized trials that use ART as their basis are planned,³⁵ and the results could determine the conclusive benefit of this successful intervention.³⁶
  Still, resource constraints, logistical hurdles, emergence of drug-resistant viral strains, adherence to therapy regimens, and risk compensation remain concerns that scientists, health care providers, policy makers, and communities must confront if the individual and public health benefits of treatment are to be fully realized.³⁷

  What CDC Is Doing

  Much of CDC’s funding supports and expands prevention services for persons living with HIV, including
  • Linkage to care and treatment, and interventions to improve retention in and re-engagement to care, prevention, and treatment for people living with HIV.
  • Referral to other medical and social services, such as substance abuse and mental health services.
  • Behavioral interventions and other risk-reduction services for HIV-positive persons and their sexual or needle-sharing partners to reduce the likelihood of HIV transmission.
  Three evidence-based interventions have proved effective in treatment settings and can be delivered by providers as brief messages during clinic visits: Partnership for Health, Options, and Positive Choice.
  CDC’s Prevention IS Care also emphasizes ongoing, brief prevention counseling to help health care providers integrate into routine care simple approaches to prevent transmission by persons living with HIV. Medical visits provide a vital opportunity to reinforce HIV prevention messages, discuss sexual and drug-related risk behaviors, diagnose and treat other STDs, review the importance of medication adherence, and foster open communication between provider and patient. 
  
  Expanded HIV testing efforts will help more people know their status so that they can get life-saving treatment and will strengthen the impact of efforts to increase adherence to treatment, particularly in areas where large numbers of persons remain undiagnosed. 
  
  Additionally, CDC and the Health Resources and Services Administration have supported studies that suggest several promising opportunities to improve retention in care, including collaborating with other service providers to identify persons poorly retained in care, enhancing outreach programs, and addressing unmet psychosocial needs

Early Treatment With Anti-HIV Drugs Stops Transmission Between Partners

http://healthland.time.com/2011/05/13/early-treatment-with-anti-hiv-drugs-stops-transmission-between-partners/
Alice Park



Researchers report yet more tantalizing data that the antiretroviral drugs doctors currently use to treat HIV infection could also be effective in preventing transmission of the virus.

In a large randomized trial involving more than 1,700 heterosexual couples — in which one person was HIV-positive and the other was not — infected people who took the anti-HIV drugs reduced their risk of transmitting the virus to their partners by 96%, compared with those who did not immediately start treatment.

The results were so stark that Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), which sponsored the trial, elected to release them early and stop the global study four years before its scheduled end. All study participants are now being offered antiretroviral therapy.

These results come not long after another large-scale landmark trial (read about it here) that found evidence that using antiretroviral drugs could be an effective prevention measure. That trial included nearly 2,500 HIV-negative men in six countries, who were at high risk of contracting HIV. Those who took a combination anti-HIV pill called Truvada (a combination of the drugs tenofovir and emtricitabine) were anywhere from 44% to 73% less likely to acquire HIV, depending on how faithfully they took their medication, during the study’s three-year follow-up than participants who took a placebo.

The findings add weight to the “treatment as prevention” strategy that some AIDS scientists increasingly believe, if broadly implemented, can help slow the spread of HIV and AIDS.

The latest study was carried out in 13 countries including Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand and the U.S., and mostly involved heterosexual couples. Infected partners were randomly assigned to begin receiving antiretroviral drugs immediately at the start of the study, or to wait to start treatment until their disease had progressed (signaled by a drop in the infected partner’s immune cell count below a certain threshold). All participants were also counseled on how to protect against HIV transmission and were given free condoms.

In the group that waited to start treatment, there were 27 cases of HIV transmission from the infected person to his or her partner; all occurred when the patients were not taking antiretroviral drugs. By comparison, in the group that started treatment immediately, only one such transmission occurred.

Antiretroviral drugs work by lowering patients’ “viral loads” — the amount of HIV in body — which means they have less virus to transmit.

“The latest study really is very encouraging, and indicates that earlier therapy provides additional benefits to the treated person as well as to the patients,” says Dr. Robert Grant, a professor medicine at University of California, San Francisco, who was not involved in the current trial but chaired the group that designed the Truvada study in gay men.

In a statement, Fauci said, “This new finding convincingly demonstrates that treating the infected individual — and doing so sooner rather than later — can have a major impact on reducing HIV transmission.”

However, because the trial’s population was 97% heterosexual couples, the findings are not applicable to homosexual couples.

As encouraging as the data are, though, AIDS experts aren’t quite ready to start doling out antiretroviral drugs as a prevention strategy like condoms. For one thing, the drugs require strict adherence and must be taken daily for life in order to work.

Also, they don’t work for everyone. In a follow-up to the study in high-risk, healthy gay men, scientists tested the preventive benefit of Truvada in high-risk women (read about the study here). That trial was also halted early because it found no benefit in using the drug prophylactically in women. But some pointed out that the women in that study may not have been reporting accurately how regularly they took their medications.

That doesn’t mean the anti-HIV drugs won’t be helpful in HIV prevention. It just means that these studies are only the first in what will certainly be a long line of trials that will help scientists figure out exactly when and how the medications should be used.

And, as Grant says, anti-HIV drugs are just one in a growing list of ways to prevent HIV transmission — including male circumcision and antimicrobial vaginal gels. As these strategies are increasingly implemented, allowing more people to lower their chances of acquiring infection, the overall community viral load will drop, much the way that vaccinations reduce the circulation of contagious bacteria and viruses.

That makes it possible for HIV scientists to shift their efforts from blocking transmission of HIV back to finding a cure. And studies like this one are critical to accomplishing that goal. “Now we can look forward to winning the war on HIV,” says Grant. “This is a turning point in the epidemic. There is no question in my mind about that.”

Treatment as Prevention: How the New Way to Control HIV Came to Be

http://healthland.time.com/2011/12/01/treatment-as-prevention-how-the-new-way-to-control-hiv-came-to-be/
Alice Park

She felt she had made the best use of her time there, by targeting women in the commercial sex trade who are at especially high risk of contracting HIV. “She told me that it was devastating,” says Dr. Robert Grant, a professor medicine at UCSF and an investigator at the Gladstone Institute of Virology and Immunology. “She said, ‘We provide them with condoms, we counsel them, provide HIV testing, and we help them think through some social solutions to avoid getting exposed.’” But women were still becoming infected with HIV at extremely high rates. “She didn’t know what to do,” Grant says.It was an all too familiar story to those who study HIV. Kimberly Page, an epidemiologist at the University of California, San Francisco (UCSF), had just returned from Cambodia, where she had been conducting research on how to protect people from getting infected with the AIDS-causing virus.

There wasn’t much she could do. It was 2001, and while treatments for HIV had advanced by leaps — with the introduction of powerful antiretroviral (ARV) drugs that could reduce the body’s levels of the virus to almost zero — the prevention effort had stalled.

Yes, there were condoms, but using them wasn’t high on most people’s lists; for prostitutes and other oppressed women, using them wasn’t an option. Safe-sex counseling was proving only marginally effective, certainly not doing enough to dissuade anyone bent on having unprotected sex with multiple partners. Trials of one of the most promising new ways to prevent infection — a microbicide gel designed to kill the virus in vaginal cells — had just failed miserably. As for a vaccine against HIV, it seemed like a fantasy. Prevention efforts had hit a scientific, social and cultural wall.

Then, in 2001, the U.S. Food and Drug Administration approved a new anti-HIV drug called tenofovir. In theory, it was similar to the ARVs that had come before it, but tenofovir had some advantages over the older drugs, namely that it was a once daily pill and had relatively few side effects. That would make it an ideal vehicle for testing a new and controversial idea — using antiretrovirals not just to treat HIV, but to actually prevent it, by giving it prophylactically to healthy, uninfected people like the girls in Cambodia.

“A lot of people said this was stupid,” says Dr. Raphael Landovitz, assistant professor of medicine at the University of California, Los Angeles, Center for Clinical AIDS Research and Education. “They said it was stupid because you were giving…drugs for a prolonged period of time to someone who was HIV uninfected. You would be putting people at risk of toxicity to prevent something for which we already have a prevention strategy that works — condoms.” (Except, of course, condoms weren’t working that well at all.)

Not to be dissuaded, Grant found himself championing the “treatment as prevention” idea, and even pushed to test it rigorously in a clinical trial. In 2007, he launched the first such study of its kind, not in Cambodian girls — that country’s government refused — but in 2499 HIV-free, high-risk gay and transgendered men in Central and South America, South Africa, Thailand and the U.S. Half of the men randomly received a combination of tenofovir and emtricitabine, and half a placebo. Then, it became a waiting game. Only by comparing the rates of HIV between the two groups after a year and a half or so would it be possible to know whether anti-HIV drugs really had the potential to prevent as well as treat infection.

The evolution of every epidemic reaches a turning point, a critical shift in thinking and resources that marks, generally, the beginning of the end of the disease. When the urgent and pressing tide of new patients starts ever so slightly to wane, and when the threat of death grows ever so slightly more distant, that is the time to start thinking longer term, about how to manage the disease within a population. Now, 30 years after the human immunodeficiency virus was first identified, we may finally be coming close to that point with AIDS.

According to the Joint United Nations Program on HIV-AIDS (UNAIDS), the number of people living with HIV has reached record levels, owing in large part to better drug treatments and better ways of getting the drugs to people who need them most. HIV has gone from death sentence to a disease one lives with.

The fact remains, however, that you can’t treat every infected person, and that each infected person remains a potential reservoir of infection of other people, which is what keeps an epidemic like AIDS alive. The disease got its foothold among gay men, intravenous drugs users and commercial sex workers, but it is now being perpetuated by the much larger population of heterosexuals, who make up most of those living with HIV today.

To truly turn the tide of the epidemic, it would require a vaccine that prevents infection close to 100% of the time. Short of that, says Grant, other efforts to prevent HIV infection need to become the priority — and potentially the key to managing the disease for the foreseeable future. Using treatment as prevention in healthy people may be an important way to do that.

In 2001, when Page told him about the high rates of HIV in Cambodia, Grant had been mulling over the results of two recently published studies. The trials, one in San Francisco and the other in Rio de Janiero, had hinted that giving people ARVs immediately after exposure to HIV — within 72 hours — could lower their risk of getting infected. The problem, the researchers of those studies found, was that even when participants were explicitly told that taking the drugs after exposure could protect them from infection, a majority of people didn’t take them.

The enrollees were told about encouraging results from other studies involving health care workers who were accidentally exposed to HIV via needle sticks or by being splashed with body fluids from HIV positive patients; those who took ARVs immediately lowered their risk of developing AIDS. It was enough for the Centers for Disease Control and Prevention to recommend ARVs for all health care workers who were accidentally exposed to HIV, but it wasn’t enough to get the participants in the San Francisco and Rio studies to take the medications.

“That study brought home to me the fact that people have a hard time starting treatment after exposure,” says Grant. “You have to admit failure, admit that you failed to protect yourself in some way, and now you need to be rescued by some sort of pills. So for those reasons, we started thinking about pre-exposure prophylaxis as a possibility.”

Pre-exposure prophylaxis (PrEP) is a fancy name for giving treatment before a person even has a chance to be exposed and infected. As a way of fighting infectious disease, it isn’t entirely radical: Malaria treatment is built on the same concept, and people routinely take antimalarial drugs before traveling to endemic regions in order to prevent infection.

With HIV, studies in monkeys have shown that giving drugs before exposure is remarkably effective in protecting animals from simian HIV. And there is actually some precedent for pre-treating people as well. In Africa, giving the anti-HIV drug nevirapine to pregnant HIV-positive women is an important way to prevent transmission to the next generation. Anywhere from 15% to 45% of babies born to HIV-positive mothers will have HIV themselves, but among babies born to moms who are treated with nevirapine before, during and after delivery, transmission rates drop below 5%. “People say that if PEP [for postexposure prophylaxis] is the morning after pill, then PrEP would be like the birth control pill,” says Landovitz.

To test the validity of PrEP, Grant turned first to commercial sex workers in Cambodia for his first trial. What he didn’t count on was the perennial problem that plagues so many HIV-prevention studies. Cambodian health officials wanted assurances that if the participants became HIV positive, the researchers would provide proper care for them by providing anti-HIV medications. That was no problem, but the study then became embroiled in protests surrounding other HIV studies in neighboring Thailand, where AIDS advocates weren’t happy with the standard of care that trial participants received. Ultimately, Cambodian health officials became concerned enough that they withdrew their support for Grant’s study.

Grant then turned to the one country that, at the time, had had some success with HIV trials – Peru. Javier Lama, a professor of global health at the University of Washington and also a supporter of testing PrEP, became instrumental in enrolling gay men in Peru and Ecuador for the trial — even though the idea of studying men instead of women was radical at the time. “I was told that testing this idea in men was inappropriate,” says Grant. “Men should just change their behavior…to protect themselves, by using condoms. We disagreed, and felt that men, like women, were doing that what they could to stay safe, but it wasn’t always easy.”

As other prevention efforts started to look less and less promising, the idea of at least testing PrEP seemed a little less crazy. “People objected to it because they asked, Why treat uninfected people when we don’t even have the resources to treat all the infected people? But the thing that won the day was that it was really interesting to know if it in fact works,” says Dr. Anthony Fauci, director of the National Institutes of Health’s National Institute of Allergy and Infectious Diseases (NIAID), which became a sponsor of Grant and Lama’s study. “It wasn’t only intellectual curiosity, but the realization that under certain circumstances, it would be a useful took in the tool kit for preventing HIV infection.”

The Bill and Melinda Gates Foundation joined NIAID and expanded the test sites to include Brazil, South Africa, Thailand and the U.S.

The first set of results were promising. Men taking a daily dose of the tenofovir combined with emtricitabine cut their risk of HIV infection by 44%, compared with men taking a placebo. What’s more, the more faithfully the men took the drugs, the better their chances of avoiding infection; those who reported taking the medication 90% of the time were 73% less likely to become infected, compared with those taking placebo.

These groundbreaking results, published in 2010, were followed up by similar successes in other trials. Just this year, two studies involving some 6,000 heterosexual men and women — including couples in which one partner was HIV-positive and the other was not — found that when healthy, uninfected people took ARVs prophylactically for up to three years, they cut their risk of HIV infection by 63% to 73%.

In an ironic turn, the same failed to hold true in a study of high-risk women. In a study of nearly 2000 commercial sex workers in Kenya, South Africa and Tanzania, PrEP did not appear to lower the risk of infection, so the trial’s sponsor, Family Health International, stopped the study early, after just two years. The researchers aren’t sure why PrEP didn’t appear to work in the women, suspect part of the problem may have to with the fact they weren’t taking their medication as faithfully as they should have.

Despite the disappointing results from the study in sex workers, AIDS experts say they have high hopes that PrEP will help turn the tide of a decades-long epidemic. “Clearly, behavioral modification of putting on a condom when you are ready for a sexual encounter is more difficult to negotiate than getting up in the morning, brushing your teeth and taking a pill,” says Fauci. “The combination of the psychological and practical with PrEP means we should ask the question, Does it work? And it does.”

But that doesn’t mean it will be easy to get PrEP to the populations that are hit by HIV the hardest. And some critics of the strategy say that rather than giving drugs to the uninfected, ARVs should be reserved for those who are already HIV-positive and need treatment. When that happens, treatment in essence becomes prevention, since treated individuals who get their viral loads down to undetectable levels are less able to transmit HIV to their sexual partners.

“The argument that drugs are in short supply, as if they were a scarce mineral and therefore should be used to only treat those who are infected, is an argument I never understood well,” says Stefano Bertozzi, director of HIV and Tuberculosis at the Bill and Melinda Gates Foundation. “Drugs are not at all in short supply. We can have as many as we want. What is in short supply is money. So the question is whether using ARVs as prevention compares favorably to other prevention modalities or not. What we need to do is make sure that we fund the prevention modalities that have the greatest value for the money in terms of how much prevention we get for the money invested.”

That could mean that PrEP, which is expensive, becomes feasible only for specific groups of particularly high-risk people, such as gay men or couples with one infected partner. For other men in nations with high rates of HIV, options like male circumcision may prove more economical and practical; studies have shown that circumcision can lower the risk of HIV infection by up to 60%, which, if current plans to circumcise 80% of males in 13 of the hardest hit HIV countries in Africa are met, could save up to $16.5 billion in HIV health care costs.

“I have a bigger vision for prevention,” says Page. “We’ve got circumcision, we have some microbicides that might show promise, and we’ve got PrEP. The next phase is going to be the implementation phase — how to deal with the structural, political and cultural factors that impede progress. We are at an interesting cross roads in the epidemic, and it’s exciting.”

Prevention is not about having the solution for containing an epidemic. It’s about providing several solutions, so that the ultimate goal — protecting people from getting infected — is met.

Government-Backed Group Calls for Universal HIV Testing of Adults

http://healthland.time.com/2013/04/30/panel-releases-recommendation-for-widespread-hiv-testing/
Alexandra Sifferlin

For the first time, a federally convened panel of experts is recommending HIV testing for all adults based on evidence that early detection of the virus could lead to more effective treatment of infection.

Nearly 1.2 million Americans are living with HIV and about 5o,000 become newly infected with the virus every year, according to the latest statistics from the Centers for Disease Control and Prevention (CDC). And an estimated 20% to 25% of HIV-positive individuals are not aware they are infected.

That could change if HIV testing became more routine, which is the intent of the latest recommendation from the U.S. Preventive Services Task Force (USPSTF), which calls for HIV testing of everyone aged 15 to 65, including pregnant women, during regular checkups. The CDC already calls for testing of all adults, regardless of their risk status.

In 2005, the panel reviewed the latest studies at the time and advised that only those at highest risk of being exposed to HIV–  including people who received blood transfusions before banks began screening for the virus, people who used intravenous drugs and those who had unprotected sex with multiple partners — be screened.

But in the intervening years, new studies on anti-HIV drugs showed that the medications could keep the virus at bay and possibly even prevent infections from progressing.  The drugs were most effective, however, if patients took them soon after becoming exposed, so regular HIV screening could help more people to become aware of their status and take advantage of the therapies. The task force is recommending that  those younger than 15 or older than 65 be screened only if they are at increased risk getting infected. All pregnant women should  be screened, including women in labor who are unaware of their HIV status, since administering anti-HIV medications can significantly lower the risk of transmitting the virus from mother to child. Researchers even reported success in functionally curing a newborn of HIV infection after the infant, which contracted HIV from the mother, was given a combination of drugs within hours of birth.

In coming to its conclusion, which were published in the Annals of Internal Medicine, the USPSTF considered both the benefits and harms of screening and determined that widespread testing would identify the disease in more people and at its earliest stages, so patients can start therapy and improve their chances of keeping their HIV levels low and not passing the virus on to others. Those benefits, the panel concluded, outweighed the potential harms from screening, such as false-positive results or the side effects associated with the anti-HIV therapies, including heart problems and lipid abnormalities.

The task force members hope that universal screening will make more individuals aware of their HIV status, and place much-needed emphasis on preventing infections in the first place. Previous prevention campaigns that focused on safe sex, condom use and abstinence have only been marginally effective in reducing new infection rates. “The fact is that the best way to deal with HIV is don’t get it in the first place,” Dr. Virginia Moyer, the chair of the task force and professor of pediatrics  at Baylor College of Medicine told TIME in November, when a draft of the current recommendations was released for public comment. “Yes, we can screen and treat, and it makes a difference, but it still involves treatment that if you could avoid it, you wouldn’t want to have. If we can really focus on prevention, that would be great.”

The USPSTF’s guidelines are not binding, but the group’s advice is often followed by doctors and adopted by professional medical groups. The task force says screening should be voluntary and only done with a patient’s consent. “That was always the intent of the guidelines, but people had questions about it so we put that in explicitly to make sure it was clear. In other words, people should not be screened without their knowledge,” says task force member Dr. Douglas K Owens, a professor of medicine at Stanford University who is also with the VA Palo Alto Health CareSystem.

“HIV is a very critical public health problem and we need a better way to prevent infections and treat people who have HIV. Of course the best way to reduce HIV disease and deaths is to not become infected and our hope is that  message will get out and people will take steps to reduce their risk,” says Owens. “We hope this will provide more impetus for people to provide screening and that more people will learn about their status and that’s important because treatment for HIV is very good and treatment early in disease is important. Often people are asymptotic and they wouldn’t know they have HIV or that they are candidates for treatment. That’s why screening is important.”

Read the full recommendation statement here.

Alexandra Sifferlin @acsifferlin