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[mis à jour le 24 August 2009 à 17h56]
The “preventive” use of antiretroviral treatments has been one of the key subjects at the 5th International AIDS Society Conference in Cape Town, South Africa. Preventive? But to what extent? How can the epidemiological contexts and the constraints – social and budgetary in particular – that vary so greatly between North and South be properly managed? And why choose this instead of the vaccine option?
In the first place … because research so far is very disappointing. Professor Jean-Michel Molina (of the Infectious Diseases Unit at the Saint-Louis University Hospital, Paris) stresses that “the evaluation of candidate vaccines continues. And also of preventive vaccines as well as therapeutic vaccines that help to control the disease in the absence of treatment of infected subjects”.
But news on the vaccine front “is rather poor, admits Professor Jean-François Delfraissy, director of the ANRS (French National Agency for AIDS research). And the same is true of the local use of microbicides, the treatment of sexually transmissible diseases (STDs) associated with HIV, and infection with the HSV2 herpes virus.
The prevention message – use of condoms, stable relationships, etc – must be maintained and indeed intensified, even if it has been shown to have its limitations. Attention is therefore turning more towards a form of prevention that could be called… therapeutic.
In France, earlier screening and targeted prevention
The concept seems simple enough. “If everyone is screened, and infected individuals are treated very early, it is possible to reduce the viral load and the risk of transmission”, explains Jean-François Delfraissy. It is not a question of systematic screening, because it will have to be repeated to be effective. Rather it is a matter of offering it “far more widely.
In practice the matter is complex because, as Professor Molina points out, “how can you impose a treatment aimed at avoiding the infection of others on people who have no direct sign of the disease?” But a question asked is a question answered. In our countries, there are two possible approaches.
Earlier screening could target at-risk groups, such as young homosexual communities. It is acknowledged that in Europe – and therefore in France – the latter “has a prevalence rate that can be as high as 7% or even 8%”, explains Jean-François Delfraissy. Today, patients arrive in hospital at the clinical AIDS stage when they did not even know they were HIV positive. There are around 30,000 people in this position in France.
In order to screen earlier and treat earlier, “new screening conditions must be created” explains the head of the ANRS. And this will rely “on AIDS associations working in places such as night clubs, beaches, etc, and the person doing the screening being an AIDS association operative.” Rapid testing of the kind launched experimentally by Roselyne Bachelot-Narquin last year have been used in this way in an experiment involving the cities of Bordeaux, Lille, Montpellier and Paris.
Another idea is also making headway. This is the treatment of people in a good state of health prior to risk taking, by prescribing a course of treatment based on tritherapies taken once a day. This technique has already been used for people accidentally exposed to the disease, such as health professionals. Prevention of this kind could be used in the prostitution environment where there is a recurrent risk of infection. The idea is gathering momentum. “We expect to build a trial of several hundred individuals around mid-2010”, Jean-François Delfraissy states. Carried out in partnership with the French Ministry of Health and the Quebec health service in Canada, the operation would also involve AIDS associations. Cost considerations – treatment costs are reckoned at between €5 and €10 per day – will naturally require additional resources to be found.
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