Jul 23 2012

AIDS International Conference 2012: A Q&A with Diane Havlir

Diane Havlir Diane Havlir, MD, University of California, San Francisco and San Francisco General Hospital and Trauma Center

The XIX International AIDS Conference is taking place in Washington, D.C., this week at a pivotal point in the prevention and treatment of the disease. The World Health Organization on Friday recommended using antiretroviral medicines to try to prevent the infection in people who do not have HIV but are at high risk of transmission. The recommendation is based on recent research that found the drugs effective for many people. And, the International Antiviral Society has recommended treating all patients diagnosed with HIV with antiretroviral drugs, rather than waiting for levels of the virus to reach a certain point. Earlier treatment may help prevent certain diseases associated with HIV, including cancer, heart and kidney disease.

In advance of the meeting, Conference Co-Chair Diane Havlir, MD, chief of the HIV/AIDS division at San Francisco General Hospital and professor of medicine at the University of California, San Francisco, sat down with UCSF science writer Jason Bardi to talk about the pivotal research and global commitments being discussed in meeting sessions and hallway conversations in Washington, D.C., this week. Here are some key excerpts from that conversation, which originally ran on the UCSF News Center website.

Jason Bardi: What can we expect at the AIDS 2012 conference?

Dr. Havlir: Over the last couple of years, we’ve had breakthroughs in AIDS, mostly in the prevention area which include treatment as prevention, adult male circumcision having sustained benefits, pre-exposure prophylaxis, and data showing that early treatment benefits the individual. So, the big theme at AIDS 2012 is about how we begin to end the AIDS epidemic. The conference theme is “Turning the Tide Together,” and there is going to be emphasis on the how: how are we going to start to begin the end the AIDS epidemic? And there’s going to be emphasis on the together: who’s going to finance this, and what partners do we need to bring to the table? The way I like to explain it is that we need to think about the short- and medium-term strategies and the long-term strategies.

Jason Bardi: Your research group at UCSF is presenting quite a lot of research at the conference. Can you talk about some of the highlights?

Dr. Havlir: Sure, I would love to. When we talk about beginning to end the AIDS epidemic, one of the predominant strategies that we are looking at is something called test and treat. What that means is that we find people who are HIV infected, and we offer them treatment. It seems rather basic and simple, and it is. But the benefit serves a dual purpose. First and foremost, by putting people on treatment, we preserve their health. Now we know there’s a huge secondary benefit of putting people on treatment and that is reducing forward transmission of HIV.

An average person untreated with HIV has about 10,000 viral particles in about a teaspoon of blood. We can reduce that to a level that’s undetectable, and a person with undetectable virus has less of a chance of transmitting that virus forward. So we find people and test and treat.

In San Francisco, two years ago here in our clinic, we were the first clinic in the world to offer treatment to everyone which then became adopted as our public health policy — to offer treatment to everyone regardless of the CD4 cell count.

What we had done in the past is would wait for peoples’ T (CD4) cells to fall down until they had gotten to a certain level of their illness, in order to avoid toxicities of the drugs, and then we would start HIV therapy. Well, now we know the virus is doing harm and destruction even earlier. And the harm of the virus, the toxicity of the virus, outweighs the toxicity of the medicines.

We’ve seen progress, and we’ll be presenting [some] of this at the conference Earlier in the decade, maybe one in ten people in our clinic with high CD4 counts were in treatment; now in our clinic, one in two people are on treatment. And our group also has been working over the last two years of the concept of test and treats in rural Africa with our African colleagues in Uganda and in Kenya.

The challenges, though, are that in the United States, about 20 percent of people don’t know their HIV status but are already infected. In Africa, that’s way higher; probably about 70 percent of the people are unaware of their status.

We’ll also present data that are looking at the benefits families and children get from staying at work, and having kids stay in school, when one maintains health by finding people early and not allowing them to progress to illness.

Jason Bardi: And that’s a lesson that you’ve demonstrated here in San Francisco, correct?

Dr. Havlir: Absolutely. We know by finding people early and keeping them healthy, we stop the cascade of getting sick, dropping out of work and ending up in the hospital. The worst case scenario is ending up in the intensive care unit, which sadly still happens in this day and age, in a city such as San Francisco.

Jason Bardi: What about the rest of the country? Have other cities followed suit in terms of early treatment, test and treat strategies?

Dr. Havlir: Yes. We announced [our strategy in San Francisco] in 2010. New York announced earlier last year that they were going to adopt offering universal treatment. Washington D.C. recently announced that it’s also the official policy of that city, which as many people know is highly affected by HIV with an overall 2.7 percent prevalence on the population level. And we have heard that Georgia also is likely to move as a state to make that a policy.

Jason Bardi: I know that in some areas of medicine, there are well-documented lags between the technology and the adoption of that technology. Are things different in this field?

Dr. Havlir: The answer to that question is yes and no. I think when there are transformative breakthroughs, when we change HIV from a fatal to a chronic disease; there is rapid, rapid uptake. But the reason why I’m going to say no is because in a recent report from the Centers for Disease Control, only 28 percent of people living with HIV have viral suppression. If there was a rapid uptake of finding people with HIV and putting them on therapy, that number would be much, much higher.

[But] there’s a whole new field that has emerged over the last couple of years called implementation science, which strives to characterize the obstacles and the solutions that permit scientific advances to be put into action. That, in fact, is something that all fields of medicine, HIV included, need to improve upon.

Jason Bardi: Looking ahead, what happens after the conference?

Dr. Havlir: We’re going to ask and challenge every single person who comes to the conference to leave with at least one new thing they’ve learned and one new direction. It’s amazing what happens at the conference. The exchange of information that occurs across countries, across disciplines, helps people recharge and go back to do their work better.  People are inspired at the meeting.

In terms of what’s going to happen after this meeting — what we would like to see is a cascade of events that happen in place to seriously address the question of how to begin to end the AIDS epidemic.

>>Bonus Links:

  • Read the full interview with Dr. Havlir.
  • Read a primer on HIV infection from the online site of the Journal of the American Medical Association.

Tags: AIDS, Disease Prevention and Health Promotion, Global Health, HIV, Public and Community Health