Presentation made at the Be Heard conference in Vienna 2010.

1. TEST AND ...
TO TREAT OR NOT TO TREAT?
Roger TATOUD, Ph.D
International HIV Clinical Trials Research Management Office
Imperial College London
Vienna, 17thJuly 2010
MSM Global Forum

3. DOES IT WORK? CAN IT WORK?
 Relevance of mathematical modelling
 Velasco-Hernandez JX, et al. Could widespread use of combination antiretroviral therapy eradicate HIV epidemics?. Lancet Infect Dis
2002; 2: 487-493.
 Granich RM, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission:
a mathematical model. Lancet. 2009 Jan 3;373(9657):48-57. Epub 2008 Nov 27.
 testing all adolescents and adults at least 15 years old once a year...
 90% programme coverage by 2016 with immediate start (2010)
 The funding needed to implement the theoretical strategy for an epidemic of South African-type severity peaks in 2015 at $3·4 billion
per year (range $2·2 billion—$5·3 billion)
 Echoing the Swiss Statement
 “An HIV-infected person on antiretroviral therapy with completely suppressed viraemia “effective ART”) is not sexually infectious, i.e.
cannot transmit HIV through sexual contact.”
This statement is valid as long as:
 the person adheres to antiretroviral therapy, the effects of which must be evaluated regularly by the treating physician, and
 the viral load has been suppressed (< 40 copies/ml) for at least six months, and
 there are no other sexually transmitted infections.
 Prevention of Mother to child Transmission
 In 2008, 45% [37%-57%] of HIV-positive pregnant women in low- and middle-income countries received ARV, up from 35% in 2007 and
10% in 2004.

4. COST EFFECTIVE?
Cost-effectiveness estimates in low-
and middle-income countries
Bongaarts J Science. 2010 Jun
11;328(5984):1359-60.
“People are struggling to find resources “Virtually every day, we have to turn
to honor the commitments we have away patients who need treatment,
made.” including breast-feeding women.”
“We’re not at a cap point yet. If it gets “We have to tell them ‘There is a
worse, we’ll have another discussion.’’ freeze.’”
Ambassador Eric Goosby Dr Peter Mugyenyi
US global AIDS coordinator Joint Clinical Research Center. Kampala, Uganda
Boston Globe April 11, 2010

5. HUMAN RESOURCES AND EFFICIENCY
Healthcare Worker Country Number/1000
Malawi 0.02
PHYSICIAN
Uganda 0.12
UK 2.14
Malawi 0.28
NURSE
Uganda 1.31
UK 5.8
Malawi 0.03
LABORATORY
Uganda 0.06
PERSONNEL
UK 0.34
Source : AVERT
Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a
randomised non-inferiority trial.
Sanne I. et al, The Lancet Jul 03, 2010, Volume 376
HIV-positive individuals with a CD4 cell count of less than 350 cells per μL or WHO stage 3 or 4 disease were
randomly assigned to nurse-monitored or doctor-monitored ART care.
408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; all
participants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in the
nurse group and 179 (44%) in the doctor group.

6. IMPLEMENTABLE ?
 Developing World  Developed World
Style over stigma:
The designer sexual health clinic
that could be mistaken for a
boutique hotel.
(Daily Mail Reporter 12/05/09)
Functionality over Style:
Providing the minimum to ensure
diagnosis, treatment and care.

7. STIGMA, DISCRIMINATION, OSTRACISM
Wat Phra Baht Nam Phu, Lop Bury, Thailand Pasargadae Palace, Iran - Cyrus the great last resting place
No Testing = No Treating
Likoma Island, Lake Malawi

8. IS IT ETHICAL?
 Universal Testing or Coerced Testing?
 Treating people who do not feel unhealthy
 Evidences from Clinical Trial (START Trial – HPTN 052)
 Putting the onus on the HIV positive
“we have to be careful that "treatment as prevention"
doesn't slide into "forced treatment as prevention."
Indeed, both of these strategies expose the blunt self-
interest of the HIV negative. Maybe if we cared about
both HIV-negative and HIV-positive people equally, our
strategies might better reflect a mutual respect?

9. 100 M HURDLES
Infrastructure
Personnel
Test
Treat
Follow up
Adherence
Resistance
2nd Line

10. TEST AND TREAT... AND OTHER NPTs
Let’s not forget what worked and works.