HIV/AIDS – Keeping up the fight

[30 September 2009 - 11h44]
[mis à jour le 30 September 2009 à 12h14]

“ AIDS is not in recession and our efforts in terms of prevention and screening must absolutely be maintained”. This is the alarm that was sounded with one common voice by the 5,000 participants at the 5th International AIDS Society (IAS) Conference that took place at the end of July in Cape Town, South Africa.

Researchers, doctors and other representatives from non-governmental organisations and associations expressed their concern about the impact of the global economic crisis on the fight against AIDS. Not forgetting that the A/H1N1 virus is now a formidable competitor in the race for funding. Yet scientific advances and progress in public health have never been as great. Here is how things stand.

Professor Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, did not hide his concern at the difficulties facing the Global Fund from 2011. “We need to find tens of billions of dollars”, he told us. “Yet the last G8 did not release anything for AIDS, tuberculosis or malaria, and nothing for mother-to-child transmission”.

Faced with both an economic crisis and H1N1, experts fear that efforts in research and the treatment of the disease may have to be suspended … and this at a time when therapeutic advances are being made. “Today, we are achieving practically 90% success”, pointed out Professor Jean-Michel Molina, head of the Infectious Diseases Department at the Saint-Louis de Paris University Hospital. “And this success – characterised by an undetectable viral load, indicating the effective control of infection (ed. note) – persists for practically as long as treatment continues”. Though he still felt it important to add “that a great deal, of course, remains to be done – in terms of screening and prevention and also in terms of therapy”. In other words, there can be no easing off…

Prevention and screening – a constant and ongoing need

These experts stressed in particular the need for more effective prevention, for more systematic screening and a more active targeting of at-risk populations. Indeed, the concept of “at-risk groups” is returning to the forefront in the fight against HIV. Necessity knows no law: the most recent UNAIDS report shows clearly that the pandemic is far from being controlled. In disadvantaged countries, the number of sufferers is increasing faster than the number of patients treated. And in other countries, like France, more and more cases are being screened at the clinical stage of AIDS…

“Even though they may have shown their limits, campaigns to raise awareness must be continued”, insisted Professor Delfraissy. Circumcision reduces the risk by 50% to 60%, and we must continue to recommend it. And in the countries of the North, the epidemic continues, particularly among young homosexuals. What is new, is that people can talk about it”. Professor Molina pointed out that “in gay communities, people know who is HIV positive. These individuals seem well, so all of a sudden people think that ‘it’s not as serious as all that…’”.

There needs to be a return to responsible behaviour. Any risk behaviour must of course be followed up by precautionary screening. But checking for HIV must also become a standard part of laboratory testing. At least once in a lifetime, more if necessary. Professor Molina estimates that in France there are more than 30,000 HIV positive individuals who are unaware of their status. He also deplores the fact that 30% of sufferers are not diagnosed until they are in hospital at the clinical stage of AIDS. This was confirmed by Professor François Raffi. In his department at Nantes University Hospital, Professor Raffi receives “one to two new patients each week. My last two patients were fifty-five years old. They are married and came for consultation with me at the clinical AIDS stage. To have reached this stage today, they must have been infected eight to fifteen years ago…”

Antiretrovirals to be used preventively?

The use of condoms, forming stable relationships… these messages of prevention must be continued and indeed intensified. But today, attention is also turning towards a form of prevention that one might call therapeutic.

Vaccines? Not really. Research in this field is still very disappointing. As Professor Molina points out, “evaluation of candidate vaccines continues – of preventive vaccines but also of therapeutic vaccines that can help control the disease in the absence of treatment for infected subjects”.

Moreover, the use of antiretroviral drugs as a “preventive” measure is now on the agenda. Indeed it was widely discussed at the IAS Conference. Professor Delfraissy, director of the French National AIDS Research Agency (the ANRS) explains: “If everyone is screened and those infected are treated very early on, it is possible to reduce viral load and the risk of transmission”.

Although it may not be simple in practice, earlier screening could target at-risk groups: the young homosexual community, for example, where the prevalence of HIV is estimated at between 7% and 8%. But in order to screen earlier and treat earlier, we need “to develop new screening methods/i>”, continued the ANRS director. We need to rely on HIV/AIDS associations and take the operation out into places like nightclubs and beaches, and use association operatives to do the screening. The rapid testing launched experimentally by Roselyne Bachlot-Narquin last year is now being used in an experiment involving the cities of Bordeaux, Lille, Montpellier and Paris.

Another idea that is making headway is that of treating people who are in a good state of health before they take risks by prescribing them single daily dose tritherapy treatments. This technique has already been used to treat people accidentally exposed – health professionals, for example. This form of preventive treatment could be used in the prostitution environment where there is a recurring risk of infection. “We are planning to construct a trial involving several hundred people towards mid-2010”, explained Professor Delfraissy.

Treatment – long-term safety and tolerance are imperative

In the future, a challenge facing all these specialists is treating their patients over the long term, and in safety. In the countries of the North, AIDS is increasingly being seen as a chronic disease. As Professor Raffi (Nantes) pointed out: “we shall have to treat some patients for thirty or forty years. It is therefore important to look for tolerance and durability of treatment”.

A multinational study bringing together eighty-three teams was presented in Cape Town. It demonstrated the superiority of using a triple combination of inverse transcriptase inhibitors (INTIs) over the more traditional combination of protease inhibitors and INTIs. Coordinated by Professor Vicente Soriano of Madrid, the ARTEN study compared two combination options with the pairing of Tenofovir/Emtricitabine (Truvada®). Five hundred and sixty-nine patients received either a combination of Atazanavir and Ritonavir – two protease inhibitors – or Nevirapene (Viramune®).

Available for the last 13 years, Nevirapene is the oldest of the non-nucleoside inhibitors of inverse transcriptase. Used worldwide and already available in generic form, it has been the subject of many humanitarian and/or compassionate distribution programmes. Nevirapene is the reference drug in the prevention of mother-to-child transmission (MTCT) of HIV.

This study has shown “that in 67% of patients compared with 65% (in the other group), combined Truvada®/Viramune® therapy rendered viral load undetectable at an early stage”. Furthermore, its impact on blood lipids is very favourable, with a “decrease in LDL cholesterol – the so-called “bad” cholesterol (ed. note) – and an increase in HDL-cholesterol levels to more than twice that obtained” using protease inhibitors. This is a major factor because lipid problems are a constant concern for HIV/AIDS sufferers. They can cause bodily deformities and increase the risk of cardiovascular disease.

Despite the considerable progress made in recent years, the situation is still far from encouraging. Vigilance remains lacking and the inequalities that exist are also intolerable: according to UNAIDS, of the thirty-three million people in the world living with AIDS, twenty-two million can be found in sub-Saharan Africa, where only 35% of their therapeutic needs are being met. Indeed, in 2007, over 75% of deaths caused by the disease occurred in this part of the world.

Source : Progress Report WHO-UNAIDS-UNAIDS, 19 September 2009 - from our special correspondents at the 5th IAS Conference, 19-22 July 2009, Cape Town (South Africa).

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