What Works for Women and Girls

Treatment May Be a Successful Strategy in Reducing Transmission“Given the dramatic effect of ART on viral load, it is reasonable to consider using treatment ofindividuals infected with HIV as a means of preventing HIV transmission” (Dieffenbach andFauci, 2009: 2380). However, “…there is insufficient evidence to formulate guidance on therole of ART in HIV prevention, both at the level of the individual and the population” (Attiaet al, 2009: 1402). Emerging evidence shows that “reducing virus levels with antiretroviraltherapy…reduces the risk of HIV transmission in a variety of settings” (IAS, 2010: 3). Resultsare awaited from HPTN 052, an ongoing, prospective, two-arm, randomized, controlled, multicenterstudy with 1,750 HIV-positive people and their HIV-negative sexual partners, started in2008, with results in five years. In the study, the HIV-positive partner goes on treatment whenCD4 counts go below 200; the study endpoint is seroconversion of the HIV-negative sexualpartner (Godbole et al., 2008).Though ARV treatment can reduce transmission through reduced viral load (Attia et al.,2009; Vernazza et al., 2008), condom use is still necessary to increase protection for bothHIV-positive and HIV-negative sexual partners. “While the use of HIV treatment as preventionis emerging as an exciting component of scaled up AIDS programmes, further researchand clarification is needed. The reliability of projections developed from mathematical modelsis limited by the accuracy of the assumptions on which a model is built and by the realities ofimplementation. Additional areas of uncertainty range from questions regarding the accuracyof mathematical models used in recent publications to questions regarding the acceptabilityand impact of massive scale up of HIV testing, and of long-term treatment in people whereHIV treatment may not yet [be] medically indicated but is being prescribed to prevent HIVtransmission. Many of these questions will be addressed by studies planned or underway”(IAS, 2010: 6).Treatment Alone Will Be Insuffi cient in Reducing TransmissionGiven the unknowns and the inadequate availability of medications, treatment alone is insufficientin reducing and preventing HIV transmission. Additional factors must be addressed tobridge the divide that exists between HIV prevention and treatment activities in order to reducetransmission of the virus, as well as to meet the SRH needs and fertility desires of women.“The historical separation of treatment and prevention and the focus of prevention on uninfectedindividuals are counterproductive in a setting [such as South Africa] where more than30% of the sexually active population is infected with HIV” (Abdool Karim et al., 2009: 931).The new standard of care for all people living with HIV should include counseling, support,condom negotiation skills, and provision of male and female condoms to reduce transmission.In addition to antiretroviral therapy “all treatment programs should provide patientswith routine risk-reduction counseling, access to condoms and other prevention tools, andother prevention services in their clinical settings” (Global HIV Prevention Working Group,2008: 23).176 CHAPTER 7 TREATMENT