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HIV-infected infants are at high risk of disease progression and death. Until 2008 guidelines recommended waiting until the infant displayed symptoms, or had a weakened immune system before starting treatment. The CHER trial found that starting infected infants on antiretroviral therapy as early as possible substantially reduced mortality compared with waiting until they developed symptoms or their immune system weakened. These results led quickly to changes in guidelines for treating HIV-infected infants issued by the US, World Health Organisation (WHO), Paediatric European Network for Treatment of AIDS (PENTA) and South Africa. These revised guidelines, if fully implemented along with early infant diagnosis, would reduce the number of infant deaths because of HIV by 76%, saving the lives of approximately 46,800 infants globally each year.
In 2011, 34 million people worldwide were living with, and 1.7 million died from, HIV/AIDS. Since 2002, HIV-positive people have benefited from research by the Antiretroviral Therapy Cohort Collaboration (ART-CC) based at University of Bristol (UoB). Research on the timing of ART led to updated international HIV treatment guidelines that recommended starting treatment earlier. Research on life expectancy highlighted the benefits to patients of earlier ART, and was used by policy makers, clinicians and patient groups to promote earlier treatment. Patients are now starting treatment earlier resulting in increased life expectancy. Insurance companies changed their criteria for providing life insurance, influenced by ART-CC.
Our work with the World Health Organisation (WHO) had a major impact on global HIV treatment priorities at a critical time in the roll-out of anti-retroviral treatment (ART) worldwide. Concern had been expressed that if ART was provided without simultaneous monitoring of HIV viral load to determine switch in treatment, this would lead to an epidemic of drug resistant HIV. It was argued that viral load monitoring should be introduced as a priority, despite the fact that this was expensive and would inevitably divert resources from ART provision. We used a simulation model to predict the impact of lack of viral load monitoring and showed that while development of viral load assays was important, ART should be prioritised. As a result, the roll out of ART continued despite continued lack of viral load monitoring, and there are now over 9 million people on ART.
HIV associated plasmablastic multicentric Castleman's disease (MCD) has emerged as an uncommon disease over the last decade that is a significant cause of mortality in people living with HIV infection. Advances in our understanding of the epidemiology, virology and immunology of this disease led Professor Bower to recognise the potential for using targeted monoclonal antibody therapy. This has dramatically improved the survival of patients with MCD and is now advocated in the national treatment guidelines and is widely adopted in clinical practice globally. Moreover, the use of plasma Kaposi's sarcoma herpesvirus virus levels as a tumour marker for MCD has been developed.
Researchers from St Georges have evaluated and optimised anti-fungal therapy for cryptococcal meningitis, the commonest cause of adult meningitis in sub-Saharan Africa. They have developed a "screen-and-treat" strategy to prevent the development of clinical disease in HIV-positive patients, and with collaborators developed and tested a novel point-of-care diagnostic test. These advances have led to changes in and development of a series of international guidelines and application of these new strategies in parts of Africa. A case for reduced costs of amphotericin was advanced by the group who were instrumental in reducing these costs in South Africa, allowing wider drug provision.
Research carried out by LSHTM into the effects of male circumcision on HIV prevention has led to important policy recommendations by WHO and UNAIDS, the joint UN Programme on HIV/AIDS. The research showed a strongly reduced risk of HIV infection among circumcised men, and modelling studies estimated that male circumcision programmes in 13 priority countries in Africa could avert 4m HIV infections by 2025. Members of the research team serve on key international advisory groups, and these results have been widely used to underpin international policy guidelines.
Rosengarten's work during the past fourteen years has provided the HIV field with new ways of rethinking otherwise seemingly intractable problems of more effective prevention. Despite over 30 years of biomedical and social research, and policy and programme implementation, the HIV epidemic continues to grow. The efficacies of repurposing potentially toxic and partially effective antiretroviral drugs for prevention in those perceived at risk of infection has thus come under scrutiny. It is in this context that Rosengarten's work has intervened and introduced an alternative approach to prevention that directly scrutinises the social contexts in which people live and work with HIV. Through this approach and her active engagement with clinicians, policy makers, scientists and advocacy groups she has contributed critical insights that have been incorporated into approaches to HIV prevention in practice.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organisation (WHO) regularly report estimates for the prevalence of HIV and associated metrics for almost every country in the world. These statistics are essential for tracking the scale and the impact of HIV epidemic and are used routinely in the policy decisions and funding allocation decisions of national governments and international donors and therefore have a major impact on international public health. The methods underlying those estimates were originally developed, and continue to be refined and updated, by an international group of researchers at Imperial College London.
In order to reduce morbidity and mortality from HIV/AIDS, tuberculosis and other chronic diseases, effective and cost-effective interventions to strengthen primary care through in-service nurse training were put in place as standard practice throughout South Africa (population 50 million), based on our research. This programme has so far trained 1500 trainers in all 8 provinces, who in turn have trained 18,000 primary care professionals in 1900 of all 3500 clinics nationally. South Africa, with 5.8 million HIV+ people, and 500,000 newly infected with tuberculosis each year, based its Nurse Initiation and Monitoring of Antiretroviral Treatment policy on our training package and trials. These were landmark changes in primary health policy and provision in South Africa. The training methods and materials are also being used in Gambia, Malawi, Brazil and Portugal.
The Unit's research into HIV testing has led to impacts on health policy (WHO and NICE guidelines) and services relating to HIV testing amongst vulnerable populations across Europe, and particularly, Scotland. The policies related to the frequency of HIV testing, increases in sites available for testing, and the scope of interventions to promote testing. These policies have contributed to significant increases in HIV testing, and a reduction in undiagnosed HIV infection, HIV related ill-health and AIDS deaths. For people living with HIV, this has enabled improved quality of life, better health and contributions to society.