Plenaries30 years on: What can HIV treatment do for HIV prevention?
Introduction
In the 30 years since the identification of acquired immunodeficiency syndrome (AIDS) and its causative agent, human immunodeficiency virus (HIV), knowledge and understanding of the epidemiology, causal factors and pathogenesis have grown rapidly. HIV presented a huge problem for the public health community when it first emerged. Acquired immunodeficiency syndrome was highly stigmatized, generally fatal, and poorly understood. In 1981, whilst it was recognized that there was an association between AIDS and some aspects of a homosexual lifestyle or disease acquired through sexual contact, there was great uncertainty about the cause or the course of the disease. There was great fear because death following an AIDS diagnosis was generally rapid, and there was uncertainty about how far the epidemic could or would spread. People were becoming infected with HIV with no symptoms, and many had acquired it before the first cases of AIDS were recognized. For gay men in particular, the HIV epidemic was devastating.
The public health authorities needed to respond quickly and effectively. Early activities in San Francisco led by the gay community focused on behavioural change. Similar work in the UK led to a rapid decline in risk behaviour. In the UK, the approach subsequently adopted by the public health authorities, informed by both the activity in San Francisco and by the gay communities themselves, was to distribute health education leaflets to every household in the country, explaining what was known about routes of transmission, both through unprotected sex and through drug use. This changed the way in which the population at the time engaged with dialogues on sexual behaviours, making discourse more public. However, the epidemic has continued to thrive.
This paper reflects on the development and impacts of treatments in the context of an unfolding epidemic, and on the opportunities available as part of the next generation of preventative practice.
Section snippets
The initial spread of HIV and AIDS in the UK
Research in the 1980s at Middlesex Hospital showed that, while there were, as yet, few cases of AIDS, an epidemic of HIV infection had spread silently through the community. The causative agent of AIDS was first isolated in 1984, and a reliable diagnostic antibody test was developed soon afterwards at Middlesex Hospital. This enabled anonymous testing of samples of stored blood from gay men attending the clinic to measure the proportion infected with HIV, as measured by HIV antibody levels. In
The current situation
HIV has continued to spread globally. In 2010, it was estimated that 34 million people were living with HIV worldwide. This number is rising. In 2010, 1.8 million people died from AIDS-related conditions, and a further 2.7 million became infected. Most live in countries where access to treatment is limited. Two-thirds of those living with HIV reside in Sub-Saharan Africa. Nevertheless, UNAIDS estimate that the global incidence of HIV is now declining.
To date, there is no cure for HIV and AIDS.
Looking forward
Broadly, HIV transmission can be reduced by decreasing infectivity of those infected, decreasing host susceptibility to the infection, and altering risk-taking behaviour. Individually, each of these areas offers significant potential, but a programme that draws on a combination of these approaches is needed to reduce the incidence of HIV/AIDS at a population level. However, as Table 1 shows, prevention research still has a long way to go.6
With better understanding of the biology of HIV
Conclusion
Based on the evidence, there is a strong case for renewed prevention efforts to reduce the levels of new cases of infection, which persist despite the availability of diagnosis and treatment. Despite major technological advances, 25 years of health education and the availability of ART, the incidence of HIV remains high throughout the world. In the UK, increasing numbers of individuals are living with HIV and the absolute prevalence of numbers untested has remained constant. Studies of sexual
Ethical approval
None sought.
Funding
None declared.
Competing interests
None declared.
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