Barbados has scored a small victory in the fight against HIV and AIDS. Local researchers have made a groundbreaking discovery – HIV positive persons who go on Anti-Retroviral Therapy (ART) here, have been showing a suppressed viral load. To put it simply, they are non-infectious.
This phenomenon was documented by Professor of Vascular Research at the University of the West Indies (UWI), Cave Hill Campus, Clive Landis, and head of the National HIV/AIDS programme, Dr. Anton Best, in a body of research entitled: Ten-Year Trends in Community HIV Viral Load in Barbados: Implications for Treatment as Prevention. It was a collaboration between the UWI and the National HIV/AIDS programme and was published in a leading international medical journal called PLOS One in March, this year.
The research tried to ascertain what proportion of the HIV – infected population?? which is about 1.2 per cent of the adults in Barbados – had a suppressed viral load. They discovered that 26 per cent of persons on ART had a completely suppressed viral load.
For the sake of clarity, a suppressed viral load simply means that you have little or no virus in your body. If you are receiving ART drugs and they are effective, then the virus is dampened down to the point where it is almost undetectable – it hasn’t gone but it is undetectable.
According to Professor Landis, the significance of this is two-fold.
“It is important to the patient because as you know, if your treatment is effective and you stay on your treatment the death sentence is gone. But what has also been appreciated…is that there is a public health benefit, because if you have suppressed viral load, in essence you are non-infectious. That is quite a strong statement to make but it is entirely accurate. If you have suppressed viral load you cannot transmit the virus,” he emphasised.
The Professor also believes that viral suppression is much better than what the current statistics indicate. This is where he dropped another bombshell – health authorities have also discovered that quite an unusually and surprisingly large number of Barbadians who are not on ART also have a suppressed viral load.
“We have done some research with Oxford University and it appears that we have inherited a fortuitous set of HLA (Human Leukocyte Antigen) genes which actually render the virus somewhat unfit so we have a little bit of natural immunity here in Barbados and when you come onto the ARTs we [reduce the virus even further],” he said.
The research shows that within months of going on ART, the suppression rate is rapid but it will only work if the individual is on therapy all of the time. However, stigma and discrimination still hinder a lot of HIV-infected persons from accessing treatment.
“The treatment, and I mean state-of-the art treatment, is available here and it has benefits all round; to the patient [and] to the public. But a lot of patients do not access this treatment because they are still deathly scared of the discrimination they face coming to the clinic.?? They are worried about the healthcare profession and how confidential their information is – that stigma is still enormous.
“When we did our analysis on the proportion of the whole population that had suppressed viral load, once the person has registered in our programme we outperform. The only other country that has reported this is the [United States] but, unfortunately, only a small proportion of our known HIV-infected persons ever come for treatment. We must overcome the fear in our society and the stigma that is exerted on persons with HIV because we can now treat this and people need to come forward,” Professor Landis said.
“The public must be aware that it is over blown… all of this fear. HIV, and the way it is transmitted has never changed. There is no chance of transmission through casual contact so there is no need to be afraid of someone who has HIV so we need to overcome these barriers in our society so more people can come for this treatment which really is outstanding here,” he added.
He observed that half of all patients who go for treatment do so rather late so they are placed on ART right away.
Anti-retroviral therapy – a triple therapy – has been available since 2002 and once patients adhere to the strict regimen, they can return to all normal function and have the same life expectancy as someone who is uninfected.
While the new local research is to be celebrated, the Professor said the fact that ART could cut down on HIV transmission had been known for quite some time.
“I think [people] will be familiar with the success of the treatment of pregnant mothers – there hasn’t been an HIV positive child birth in six years [in Barbados] despite the fact that a number of mothers who have HIV have given birth to children and that cuts down on what we call vertical transmission which is from mother to child.
“And so, the interest has been whether one can cut down on sexual transmission as well, if treatment is at the required level. This research has been disappointingly slow to come about because really the key paper was there since 2001 showing that the level of virus in your blood stream actually determined how infectious you were in sexually transmitting the virus. But …I guess because it was a bit controversial and I think people were worried it was going against messages of self-protection but the truth matters,” he explained.
Over the years, the side effects of the drugs used in ART have greatly diminished. But the risk is quite neglible, said Professor Landis compared to the overall benefits.
He pointed out that although Barbados and the United States were the only countries so far to report a suppressed viral load in their HIV-infected populations, what is now being coined as “treatment as prevention” was taking place in other countries.
The Professor explained that most Caribbean countries had reported similar plateauing and a gradual decline of the epidemic in the last four to 10 years.
“We do think that treatment as prevention is a component of this although there’s no clear proof of that,” he surmised.
The new findings, he added, had implications for when treatment was started. Before, health officials waited until the patient had crossed certain thresholds to then start treatment. There were a number of reasons for this – the patient would be on this medication for the rest of his or her life and the first generation of drugs had quite a few side effects. So, it was prudent to wait until the patient really needed it but that thinking has now changed, said the Professor, because of the public health benefit of being on treatment.
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He sees Barbados moving towards a “test and treat” system where when a person tests positive for HIV, they go on therapy sooner.
“It is a far way from being a reality in most of the rest of the world because we are not even putting enough patients who need treatment onto therapy with the existing guidelines let alone ramping that up to treat everyone who has tested positive. But really that is the movement we are headed towards.
“This raises big issues to do with funding. These drugs are not cheap and the question is can we afford to do that? But then the answer might be can we afford not to do it because we are exerting this [public] health benefit. I think Barbados has been very mature and sensible about this and has actually commissioned a health economic analysis to see whether it can afford to increase treatment and extend it to more patients earlier in their disease and what the expected benefits would be in terms of cutting back the epidemic. This is ongoing research and I think it is a very sensible step,” Professor Landis pointed out.
He acknowledged that one of the greatest challenges that faced those on the frontlines of fighting this disease was the fear of finding out one’s HIV status.
“People have to overcome their fear and come and get tested because until you’re tested and you know whether or not you have HIV nothing happens… I would love to see anybody who has tested positive for HIV to come into the programme, get treated and get their life back. All they have to do is go to their doctor – the national treatment programme is not advertised freely – and [the doctor] will know where to refer them,” he said.
With this new research out in the public domain, Professor Landis hopes to see AIDS – the end-stage of the disease – become a thing of the past.
“I don’t ever want to talk about AIDS again. AIDS is totally unnecessary; nobody needs to suffer from AIDS. HIV okay, if you become infected you have a virus; many of us carry viruses around with us. AIDS is the death sentence. There is no reason for anybody to progress to AIDS with the treatment that we have,” he emphasised.