Time to accommodate antiretroviral-based HIV prevention

Abstract

e400 www.thelancet.com/hiv Vol 3 September 2016 In The Lancet HIV, Aghaizu and colleagues present results from their analysis of repeated, cross-sectional surveys coupled with anonymous HIV testing to try to explain why HIV incidence remains high in gay and bisexual men in London, UK. The authors sought to explain why incidence might be sustained, despite improvements in frequency of HIV testing and treatment uptake since 2000. The fi ndings show the value of repeated, behavioural surveillance of an HIV-aff ected population, not only in the identifi cation of behaviours that explain epidemic trends, but also to suggest potential areas for intervention. Sadly, few jurisdictions have initiated or sustained investment in behavioural surveillance, so, in many locations, the direction in which community norms are shifting and the practices that need attention Notably, the fi ndings of this study are only generalisable to patients who are stable and well established on ART. The median time on ART before randomisation in this trial was 6 years and children had been virally suppressed for at least 12 months. Additionally, the results cannot be extrapolated to children who have had previous treatment failure, or to ART containing reduced doses of efavirenz (equivalent to 400 mg for adults) or indeed to other long-acting ART regimens. The follow-up period was short and the planned 2 year trial extension will provide data for longer term sustainability of the short cycle treatment strategy. Other questions remain to be answered before short cycle treatment can become a viable option. The trial was done in tightly controlled conditions with intensive viral load monitoring. Research is needed to understand whether the trial could be safely implemented in resource-constrained settings where routine viral load monitoring is unavailable or infrequent. Further research could also assess short cycle treatment with the newer long-acting drugs becoming available that have a higher barrier to resistance and are more tolerable, such as tenofovir alafenamide and dolutegravir. Viral suppression is the ultimate goal to improve health outcomes and reduce HIV transmission, thus conferring individual and public health benefi ts. Optimum adherence to ART is crucial to ensure sustained virological suppression. Adherence to treatment of chronic illnesses drops off during adolescence and unfortunately HIV is no exception. Adolescents face several barriers to adherence, and our experience is that no single intervention will be suffi cient to ensure the high levels of adherence needed to maintain virological suppression. There fore, we need several diff erent approaches in our armamentarium to support adherence in this age group. We now have a promising and innovative option on the horizon that could be off ered to young people who face the prospect of taking lifelong ART.