Pursuing universal antiretroviral therapy in Africa – an interview with Marie-Louise Newell
Marie-Louise Newell MB, MSc, PhD is Director of the Africa Centre for Health and Population Studies in South Africa. She recently moved from University College London Institute of Child Health, London to the University of Southampton where she is Professor of Global
Health. She is also Professor of Health and Population Studies at the University of KwaZulu-Natal, South Africa. She is an international expert on HIV epidemiology with a special focus on pregnancy and childhood, and the impact of HIV and its treatment on populations. On 25 June 2013 she will deliver a Ruysch lecture at the AMC, Amsterdam on “Strategic Use of Antiretroviral Therapy in High HIV Prevalence Countries”. We spoke to Prof. Newell prior to her visit to Amsterdam.
Could you please explain a little about your background?
I originally studied medicine at the University of Groningen in the Netherlands before moving to the UK and studying Medical Demography at the London School of Hygiene and Tropical Medicine. I then went on to gain my PhD in epidemiology from London University. From 1987 to 2006 I led research in Europe on infections in pregnancy and childhood focused mainly on HIV and HCV. I was also involved in studies on the role of breastfeeding in mother-to-child transmission of HIV particularly in sub-Saharan Africa. In 2005, I became Director of the Africa Centre for Health and Population Studies in KwaZulu-Natal in South Africa.
Could you please explain the work that the Africa Centre for Health and Population Studies carries out?
The Africa Centre is located in KwaZulu-Natal, a rural setting located approximately 2½ hours drive north of Durban. The Centre, established in 1998 and funded by the Wellcome Trust, carries out research focussed on the impact of HIV on a rural population. The Centre also researches the impact of antiretroviral therapy (ART) on this population. The surveillance area covers a region of 430 square kilometres and a population of 90,000 people in 12,000 households. Roughly 2-3 times a year we speak to key informants and gather information on births, deaths and relocations relating to members of each household. Since 2003 we have carried out surveillance in adults (15 years of age and older) and asked a range of personal questions about topics such as health, chronic diseases, HIV and sexual partnerships and then we also take a blood sample to test for HIV. Each year we test about 11,000 adults and from this we can see where there are pockets of infection and how the endemic is changing. We have also established a partnership with the South African Department of Health in the Hlabisa sub-district to provide HIV treatment and care, resulting in more than 24,000 HIV-infected people initiated on treatment by end 2012.
We have found that the incidence of HIV infection is increasing in this setting, with approximately 25% of all adults infected; the increasing prevalence of HIV over time is due to more people living for longer with the infection. The introduction of ART has made a huge impact on extending life expectancy, especially in adults aged 25-50 years.
During the upcoming Ruysch lecture, you will discuss two recent papers that were published in Science. Could you explain in broad terms the main findings of these papers?
The first paper is titled “Increases in adult life expectancy in rural South Africa: Valuing the scale-up of HIV treatment” and shows that through using ART there is a marked decline in mortality rates, therefore leading to an increase in live expectancy of the entire population. Before ART, people in this population who were alive at age 15 years could expect to live to an average age of 50 years. Now, with ART the life span has increased to approximately 60 years. We expect that in the next few years life spans will become similar to those of the pre-HIV era.
The second paper is titled “High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa”. In South Africa until mid-2011 HIV infected adults were eligible for treatment only if they had AIDS or a CD4 cell counts less than 200 cells/µl. This treatment eligibility threshold was then increased to less than 350 cells/µl for all adults.
Until our study, existing estimates of the effect of HIV treatment on prevention were based on statistical modelling. There was also the HTPN 052 trial in serodiscordant heterosexual couples which showed that participants on ART were much less likely to infect their partners than those that weren’t. This led to speculation of what may happen at a population level. However, this trial was run under controlled conditions and it was unclear to what extent the results could be applied to communities where stable, monogamous couples are not the norm.
The study that we carried out was in a “real-world” setting with a large population. We were able to show that on a population level, with ART being given to HIV-infected people in advanced stages of disease, that there was a significant reduction in the risk of acquiring HIV. We showed that even with only 20% of HIV-infected people receiving ART, there was a substantial reduction in risk of HIV infection. These results are very exciting. If the proportion of people on ART could be increased to 50% of HIV-infected people, there would be an even larger effect.
What do you believe will be the long-term risks of ART, particularly in terms of the spread of HIV?
That’s an interesting question as clearly it is likely that eventually there will be disadvantages. For one thing, we are starting to hear comments that young people don’t consider HIV to be such a big deal anymore, and as a result they may engage in more risky behaviour, which would be a reaction similar to what is seen in the gay communities in Europe. This would be a disaster, as ART alone will not eliminate the epidemic, but other forms of prevention such as reduced risky sexual behaviour, condom use and male circumcision will be needed in combination.
There are also risks in service delivery where till now the focus has been on getting more people on therapy, and not so much on the quality of the care, long-term therapy and adherence. Also, the side effects of therapy may become a burden.
Further, as pregnant and breastfeeding women are identified as HIV-infected, they are immediately eligible for ART, to prevent mother-to-child transmission. The babies that are born to these women are highly likely to be uninfected but will have been exposed to ART in foetal and early life. The big question is then: What is the short and longer-term impact of ART on these infants? That is an area of research that needs pursuing. In fact, one of the reasons I will be in Amsterdam on 25 June is for the thesis defence of one my PhD students, Madeleine Bunders, who has carried out research on ART in pregnant women and the effect on the infant.
Ruysch Lecture Marie-Louise Newell
Date: 25 June 2013, 17:00-18:00
Location: Lecture Hall / Collegezaal 1, AMC, Meibergdreef 9, Amsterdam
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