Nationwide Antiretrovirals Cut New Infections by 44%

Heather Boerner

July 25, 2017

PARIS — HIV treatment as prevention, which had very promising results in the HIV Prevention Trials Network (HPTN) 052 study, has been put to the test in the real world, and has passed with flying colors.

Welcome to Swaziland, where an increase in viral suppression — from 34.8% to 71.3% of all HIV-positive adults — led to a 44.0% decrease in new infections.

"It's real, documented evidence that you can translate science into programs," said American Ambassador Deborah Birx, MD, special representative for health diplomacy and head of the President's Emergency Plan for AIDS Relief (PEPFAR).

"It's exciting to see it go from empirical evidence to clinical trials to programs," she said during a news conference here at the International AIDS Society 2017 Conference.

Swaziland, which is nestled between South Africa and Mozambique in sub-Saharan Africa, is only 6704 square miles, is largely rural, has a median age of just 21.4 years, and has the highest HIV rates in the world. About 220,000 of its 1.4 million residents are living with HIV.

Scaling Up Antiretrovirals at Ground Zero

When a nationally representative sample of HIV-positive adults revealed, in 2011, that only 32.7% of the population had an undetectable viral load, the country leapt into action.

People were dispatched to test residents of every village and town and to get infected individuals on antiretroviral therapy as soon as possible, said Velephi Okello, MD, deputy director of Health Services in the Ministry of Health for Swaziland.

The follow-up study, with a nationally representative sample of 10,934 people 15 years and older, revealed something that surprised even Dr Okello, who served as the country's coordinator of antiretroviral treatment in the mid-2000s.

Not only did the percentage of HIV-positive adults with suppressed viral loads shoot up, the incidence rate of new infections in adults dropped from 2.5% to 1.4%, even without the use of pre-exposure prophylaxis.

Estimates had shown that new infections were on a downward trend, "but we didn't think by this much," Dr Okello told Medscape Medical News. "It's exciting."

Table. Effect of Antiretroviral Therapy for All

HIV Parameter 2011, % 2016/17, % Change, % P Value
Prevalence 32.1 30.5 –1.6 .52
Viral suppression 34.8 71.3 >100.0 <.01
New infections 2.48 1.39 –44.0 .01


The more than 100 audience members applauded and cheered after Dr Okello presented the viral suppression numbers, and again after she presented the drop in new infections.

The presentation was "phenomenal," said Mininim Oseji, MD, from the Nigerian Ministry of Health, who is executive director of the Public Health Impact Research Centre in Nigeria.

Scaling up treatment in Swaziland was not just a matter of working with the PEPFAR — although that funding was essential — it also took universal testing, providing counselors to everyone who tested positive for HIV to help them get comfortable with their diagnosis and treatment, and offering differentiated care with access to fast-track services, Dr Okello explained.

Making Treatment as Prevention Work Anywhere

Treatment as prevention works, "but we have to be consistent. We have to be doing testing at the facility level to get as many people in as possible, and make sure they're linked to care and started on ART. And then you have to retain them," Dr Okello added.

Can scaling up work anywhere? It has worked in the United States, in cities like San Francisco and New York, and, more recently, in Washington, DC, where the annual incidence dropped from 1300 to just 400 new HIV infections.

But that is not the situation everywhere, said Carl Dieffenbach, PhD, director of the division of AIDS at the National Institutes of Health.

"We have a fragmented healthcare setting," he pointed out. Telemedicine could address the provider capacity and access issues, but what about the commitment?

"That's the take-home message from Swaziland," he told Medscape Medical News. "If you have the commitment, you can have success, but in the absence of commitment, things don't magically happen."

However, Dr Birx said she does not believe there is anything special about Swaziland's success.

"It shows what happens when everyone works together, and anyone can do that," she told Medscape Medical News. "It's still a person-by-person, client-by-client, community-by-community, county-by-county process that any country can do."

Dr Birx, Dr Okello, Dr Dieffenbach, and Dr Oseji have disclosed no relevant financial relationships.

International AIDS Society (IAS) 2017 Conference: Abstract MOAX0203LB. Presented July 24, 2017.

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