Ten Year Trends in Community HIV Viral Load in Barbados: Implications for Treatment as Prevention

Abstract

BackgroundTreatment as prevention is a paradigm in HIV medicine which describes the public health benefit of antiretroviral therapy (ART). It is based on research showing substantial reductions in the risk of HIV transmission in persons with optimally suppressed HIV-1 Viral Loads (VL). The present study describes ten year VL trends at the national HIV treatment unit and estimates VL suppression at a population level in Barbados, a Caribbean island with a population of 277,000, an estimated adult HIV prevalence of 1.2%, and served by a single treatment unit.MethodsThe national HIV treatment centre of the Barbados Ministry of Health has a client VL database extending back to inception of the clinic in 2002 (n = 1,462 clients, n = 17,067 VL measurements). Optimal VL suppression was defined at a threshold value of ≤200 viral copies/mL.ResultsAnalysis of VL trends showed a statistically significant improvement in VL suppression between 2002 to 2011, from 33.6% of clients achieving the 200 copies/mL threshold in 2002 to 70.3% in 2011 (P<0.001). Taking into account the proportion of clients alive and in care and on ART, the known diagnosed HIV population in Barbados, and estimates of unknown HIV infections, this translates into an estimated 26.2% VL suppression at a population level at the end of 2010.ConclusionsWe have demonstrated a significant trend towards optimal VL suppression in clients utilizing the services of the national HIV treatment program in Barbados over a 10-year period. Estimates of VL suppression at a population level are similar to reports in developed countries that applied similar methodologies and this could suggest a public health benefit of ART in minimizing the risk of sexual transmission of HIV. Continued efforts are warranted to extend HIV testing to hidden populations in Barbados and linking infected persons to care earlier in their disease.

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“…Multiple studies have shown that many infected individuals start controlling their behaviors likely to transmit infection to sex or needle-sharing partners once they are aware of their positive HIV status [ 7 – 11 ]. As antiretroviral treatment (ART) lowers HIV viral load and thus reduces the risk for transmission to others [ 12 – 14 ], early referral to medical care and early ART could prevent HIV transmission in communities while reducing a person's risk for HIV-related illness and death. In addition, voluntary HIV counseling and testing (VCT) is an important entry point to other HIV/AIDS services, including prevention of mother-to-child transmission (PMTCT), prevention and management of HIV-related illnesses, and social support.…”

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“…The importance of VL suppression as a public health tool in the fight against HIV transmission cannot be overstated. The Caribbean has earned praise from UNAIDS for recording decreasing trends in new infections [ 22 ], with strong gains recorded in prevention of mother to child transmission (PMTCT) and treatment as prevention programs [ 18 ; 23 ; 24 ]. Declining infection rates are likely to be underpinned by the prevention benefits of ART, recognized by the WHO consolidated guidelines and the regional PAHO M & E framework that identifies viral load as the key metric for evaluating patient engagement in the continuum of care [ 13 ; 14 ].…”

“…Using this threshold value, the CDC estimated 28% of the HIV infected population in the USA had optimally suppressed VL [ 17 ]. By the same methodology, viral suppression in Barbados was 26% of the HIV infected population [ 18 ]. Similar information is not available from other Caribbean countries, partly because of logistical challenges in VL testing.…”