I’m returning to this topic yet again because the French National Commission on HIV/AIDS has now published a statement on treatment as prevention.
This document discusses treatment as prevention at the individual and the population level together.
It places great importance on individual autonomy, which includes the fundamental right individuals have to make decisions on their own behalf. I have come to see the issues in a somewhat different way after reading the French document.
This document can be seen here:
It is worth mentioning again that the term “treatment as prevention” can be applied to two different situations.
At an individual level it refers to prevention of HIV transmission by sexual contact between two individuals. The Swiss statement concentrated on this aspect.
The term is also applied at a population level, where the goal of treatment as prevention is the control of the epidemic, even as suggested by some, a means to end it.
The principle underlying the proposals to use treatment as prevention in both of these situations is the same. It is the reduction in infectivity that results from the effect of antiretroviral therapy.
Unlike the Swiss recommendations that dealt only with transmission between two individuals, the French statement deals with both aspects.
Treatment as prevention is not the same when applied to individuals as opposed to populations. For example, transmission between some individuals may be interrupted by treatment without having an effect on the epidemic.
To have an impact on the epidemic additional factors that do not apply at an individual level have to be considered.
For example, the number of infected people who must be treated in relation to the total number of people who are infected must be taken into account, if treatment is to have an effect on the epidemic.
For treatment as prevention to have a greater effect on the epidemic, a larger proportion of infected people must be treated.
Canadian studies have suggested that the proportion of infected people who must be treated in order to reduce transmission would need to be increased from 50% to 75%. Transmission would be slowed but not reversed with treatment rates below 50%.
Thus the percentage of infected people who are treated is related to the extent of the impact treatment will have on the epidemic.
At an extreme, if the stated objective is to end the epidemic, as has been proposed by some, the proportion of infected people who would need to be treated would be so large that it would have to include those who do not need treatment for their own benefit.
I have written about the multitude of problems arising from this situation in previous posts on this topic. Lurking behind such an extreme proposal is the threat of coercion, and the possibility of an infringement of individual rights. Very disappointingly this aspect has been barely acknowledged in English language discussions of treatment as prevention.
However if, as I believe, an additional goal of treating infected people is to add a powerful tool to prevent transmission, we are then not stating an objective that would require the participation of individuals who do not themselves need treatment.
Admittedly, treating only those who need to be treated may not have such a great impact as also treating additional infected people who do not need treatment. Therefore we must also intensify and improve our efforts at targeted prevention education with the promotion of condom use.
But we will avoid the insuperable problems and threats to personal autonomy associated with treating individuals who do not need to be treated for their own benefit.
The goal of treatment as prevention as applied to controlling the epidemic is perhaps better stated in a different way.
It might be preferable to simply state that the goal is to provide treatment to every individual who needs it. This goal must therefore be coupled with enhanced efforts to facilitate regular testing.
If we can achieve this it is likely that not only will the individual benefit, but there will be an impact on the extent of the epidemic.
There is evidence of a reduction in HIV transmission in areas where antiretroviral treatment has been introduced. .
When we emphasize that our efforts are to identify infected individuals and make treatment available to all who need it, we eliminate all the problems connected with treating infected individuals who do not need treatment.
One reason why the French document is so significant is that it stresses the importance of individual autonomy.
It emphasizes the need to respect individual rights and adds a caution to avoid the temptation to employ coercive measures in the name of the public good. Testing is the key to any success of this approach to prevention, but testing must be voluntary and informed. As of course is a decision to receive treatment.
Here is an excerpt from the French statement that shows the concern for individual autonomy and recognizes that there is a potential threat of the employment of coercive measures.
” if screening and massively treating infected persons enables to reduce the epidemic, it could be tempting to consider population compulsory systematic screening and to voice more or less insistent summons for the treatment of persons identified as HIV positive. Should public authorities use all convenient means to implement efficient policies that strengthen screening, they need to be careful not to yield to such fallacious reasoning. The issue of improving screening efficiency surely does not invalidate any of the reasons that have hitherto prevailed for rejecting compulsory screening. Keeping screening hinged on free and informed consent remains a matter of respecting the fundamental right of the person; it is at the same time an obligation even from the public health viewpoint,
Pursuing a probably completely unworkable attempt to end the epidemic by yearly testing and treating everyone infected as has been suggested by some, is wrong. The problems of feasibility, adherence, resistance, and the threats to individual autonomy cannot be overcome.
Instead we should:
Offer treatment to all who need it.
Facilitate testing, identifying and removing barriers that impede it.
Intensify and improve our efforts at targeted prevention education.
Promote condom use and make them available.
There is a final issue.
Who needs to be treated? Certainly everyone with a CD4 count below 200. Apart from this we do not know, so until we obtain some guidance from prospective randomized studies, it is prudent, in general, to not delay treatment to a CD4 count below 350 as is currently recommended.