Reading between the lines: PARTNER2, prevention and how we are really going to reach zero transmissions
While the results of the PARTNER2 study have given us more welcome evidence that people living with HIV on effective treatment can’t pass HIV on, the vast majority of new infections come from people not knowing their status. Tackling the root causes of new HIV infections remains paramount.
Results from phase 2 of the PARTNER study have given us a lot to celebrate, with evidence to confirm that HIV cannot be passed on by gay men with undetectable viral loads. This adds to the body of research underpinning the undetectable=untransmittable message, showing that what we already knew to be true for heterosexual couples, applies beyond doubt to gay men (and anal sex) as well.
However, while this gives men with an undetectable status peace of mind and cause for celebration, it won’t give the HIV response the answer it needs to stop new infections. Luckily, we already have most of the clues.
Although we might have lacked the evidence to prove it conclusively, we have long had reason to believe that HIV isn’t being passed on by those who are adhering and responding well to their HIV treatment. The knowledge of the preventative effects of ARVs has, after all, been underpinning our efforts to prevent mother-to-child transmission these last 25 years, with expectant mothers living with HIV using ARV adherence as a way to avoid passing the virus on to their babies.
But the challenges around HIV prevention lie beyond treatment and biological interventions. If we are serious about reaching zero new infections we need to be taking a deeper look at the root causes of new transmissions. To do this we start by focusing on the right populations. The vast majority of new infections occur as a result of people not knowing that they are HIV positive and unknowingly passing HIV on. Reaching these populations and encouraging them to engage with services and test for HIV, has always been a key challenge of the HIV response and remains so. To prevent new HIV infections, we know that this is where our attention needs to be.
Likewise, we need to be taking greater efforts to tackle the structural drivers of HIV. Gender inequalities, power imbalances and lack of knowledge drive new infections, making individuals who face stigma, marginalisation and lack of opportunity vulnerable to infection. Social inequalities and marginalisation corrode individuals’ ability to negotiate condoms, access health services or make their own decisions about their sexual health. Addressing these drivers will require effort, creativity and willingness. We must embrace these challenges without losing sight of the goal: preventing new infections.
New infections are happening now – there is an immediacy to the growth of HIV incidence that requires us to act. We have tools that can protect those at risk. PrEP provides individuals with a safe and effective way of protecting their HIV negative status, at the time they need it most. However, governments and the wider response have yet to commit to the levels of distribution needed to provide this protection to everyone who is at risk.
Although the results from PARTNER2 show us how far we have come for those living with HIV – to the point where they can now live as long and as well as anyone else and without the worry of passing HIV on – we still need to stop people from becoming HIV positive in the first place. HIV still requires life-long treatment, and for many countries, this is an expense which could be difficult to bear if epidemics continue to grow. It’s far more beneficial and cost-effective to prevent HIV infections than it is to provide a lifetime’s treatment, no matter how effective and life-changing those drugs now are.
Committing to HIV prevention means focusing on those who are really at risk of acquiring and passing HIV on, and acknowledging both the depth and immediacy of the issue. To do this requires the effort and creativity to address deep inequalities that exist in society, as well as the political will to increase access to the tools we have available today.
Despite all that treatment has achieved, one thing is clear: we can’t treat our way out of this complex epidemic. We must re-commit to prevention.