French ‘treatment as prevention’ statement urges campaign on benefits of HIV testing and treatment, but cautions against compulsory testing

The idea of using HIV treatment as a means of prevention implies a paradigm shift in the way HIV treatment is regarded, a statement issued last month by the French National AIDS Council has said.

The statement on 'The appropriateness of treatment as an innovative tool for fighting the epidemic of HIV infections' first details the mathematical models and studies that indicate that putting more people on antiretrovirals could considerably reduce HIV transmission.

One such was the British Columbia mathematical model presented last year, which demonstrated that achieving an undetectable viral load in more than 50% of the HIV-positive population should result in a slow decline in HIV prevalence. The authors of the French statement point out that even in the good conditions of France, in which 72% of people with HIV are diagnosed, 85% of those are on treatment, and about 74% are undetectable, only 46% of the total HIV-positive population has undetectable viral load (the proportion in the UK, for similar reasons, would be about 43%). Higher rates of testing and diagosis, earlier treatment initiation, and higher treatment success rates will all be necessary for treatment to make a really significant contribution to prevention.

Recommendations

The statement therefore recommends:

• Campaigning by both public health departments and voluntary organisations to raise greater awareness of the benefits of HIV testing and early treatment
• The normalisation of regular HIV screening among at-risk people
• De-emphasising negative or outdated messages about the toxicity and pill burden of antiretrovirals
• Training physicians to offer treatment outside CD4 criteria to HIV patients who have difficulty in maintaining safer sex.

Cautions and concerns

The paper largely rejects the idea that spreading the news that viral undetectability reduces HIV transmission might result in behavioural disinhibition, and paradoxically raise transmission rates, by pointing out that studies have shown that people who know their status and take treatment, generally take fewer sexual transmission risks than people who do not.

It explicitly rejects the Swiss Statement of January 2008, which said that within certain tightly defined criteria, HIV-positive people with an undetectable viral load “do not” transmit HIV. It says: “[Study] Results will not…identify a specific plasma viral load threshold below which the risk of transmission would be null.” It recommends that health messages should provide information on the reduction in sexual transmission risk offered by treatments, “while indicating that a residual risk may remain”.

It raises concerns that where previously it has been possible to frame HIV prevention as an activity shared by seropositive and negative people alike, using antiretrovirals as the sole means of prevention would imply that the HIV-positive partner “wholly bears the responsibility to contain the risk for the other”.

It cautions against any element of coercion being introduced into HIV testing and treatment, warning that “it could be tempting to consider population-compulsory systematic screening and to voice a more or less insistent summons for the treatment of persons identified as HIV-positive”. Instead it recommends that screening should be more systematically offered.

It also urges the continued promotion of condoms on the basis that they remain “a reliable means enabling everyone, without knowing the serological status of their partners, to keep control of protecting themselves and others during sexual intercourse”. It adds that “entering treatment, knowing that it needs to be followed lifelong…is not a minor decision and may never be so”.

Positive messages

However the statement's tone is primarily optimistic, with a new, hopeful message about HIV treatment. In particular, it says that public health communications “should break with strategies that have hitherto implicitly focused on the drawbacks of treatment…as arguments to convince the general uninfected population to keep safe”.

It says that “reducing transmission risk through treatment is a powerful reason for seropositive persons to rest assured. It should allow them…to live their sexuality in a more peaceful and radiant way”.

Regarding HIV-negative people, it adds that treatment as prevention imposes “a new form of responsibility…on all sexually active persons to know their serological status through periodic screening and to resort to treatment in the case of...diagnoses.”

It ends by hoping that treatment as prevention may help reduce the stigma against HIV. Despite the deep roots of HIV stigma in disapproval of the activities that put people at risk, it says that “the public spread of…the observation that transmission risk is reduced in treated persons may contribute to [normalising] the idea that infected persons are no danger when they accept their status and follow treatment”. Treatment as prevention, it says, may be one way of “restoring the dignity of people living with HIV”.

The statement was published on 9 April and has recently been translated into English – the English version can be read here.