Cape Town — While universal access to antiretroviral treatment remains a dream for millions of poor people living with HIV, scientists speaking at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) are discussing the benefits of these drugs as an effective prevention intervention.

Reuben Granich of the World Health Organisation said that although three million people were receiving antiretrovirals (ARVs) by the end of 2007, 6,7-million needed it and a further 2,7-million new infections had been recorded.

Granich presented models proposing the use of antiretrovirals for the prevention of HIV transmission. He argued that these models were feasible in the light of the evidence that among others transmission of HIV only occurs from person to person, viral load is the single greatest risk for HIV transmission and antiretrovirals can lower the viral load to undetectable levels.

Granich said universal voluntary counseling and HIV testing coupled with immediate initiation on ARVs, combined with other prevention methods would see a 95% reduction in new HIV cases in 10 years, incidence would reduce from around 20 000 per million to around 1 000 per million people and the number of people living with HIV would become less than 1% by 2050.

"Initial resources would be higher, but over time, given the reduction in HIV incidence, this approach may provide cost savings," Granich argued.

"There is zero risk of transmission if the viral load is below 400 and in the United States peri-natal AIDS has virtually been eliminated," he said. In countries such as the US pregnant HIV positive mothers are identified early and initiated onto full antiretroviral therapy, seeing almost zero vertical transmission to the newborn baby during birth.

Dr Francois Venter of the Reproductive Health Research Unit in Johannesburg told delegates that the debate around when to start patient on ARVs pertained to a minority as most patients in sub-Saharan Africa started their treatment very late - the average starting at a CD4 count (cells in the immune system) of around 100.

"People spend a lot of time being counseled and die while waiting to start treatment," he said.

He said studies were showing that there was massive mortality when patients were started at a CD4 threshold of below 200 - the current policy in South Africa - and that the vast majority of patients were entering the system when their CD4 levels were between 50 and 100.

"There is poor linkage between HIV testing and access to ARVs. We should maybe not focus so much on knowing your status, but rather on delivering patients into a package of care. Many people are dying waiting on treatment because we spend so much time in the referral process," said Venter, who is also President of the South African HIV Clinicians Society.

Dr Andrew Boulle of the University of Cape Town confirmed that studies from the Free State province showed that more than 80% of patients dying in the system never received ARVs.

"We see the largest mortality before people are enrolled onto ARVs," he confirmed.