AbstractThe “HIV: Seek, Test, Treat, and Retain” session was chaired by Dr Jacques Normand, the director of AIDS Research at the US National Institute on Drug Abuse. Dr Yi-Ming Chen served as the discussant. The three presenters (and their presentation topics) were: Dr Julio Montaner (Treatment as Prevention–The Key to an AIDS-free Generation), Dr Chi-Tai Fang (Population-level Effect of Free Access to HAART on Reducing HIV Transmission in Taiwan), and Dr Zunyou Wu (Challenges in Promoting HIV Test and Treat Strategy in China)

Chen, Yi-Ming

Fang, Chi-Tai

Montaner, Julio

Normand, Jacques

Wu, Zunyou

PubMed

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HIV: Seek, test, treat, and retain 

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j o u r n a l o f f o o d and d ru g an a l y s i s 2 1 ( 2 0 1 3 ) s 4es 6Available online at wScienceDirect
journal homepage: www.j fda-onl ine.comHIV: Seek, test, treat, and retainJacques Normand a,*, Julio Montaner b, Chi-Tai Fang c, Zunyou Wud,
Yi-Ming Chen e
aNational Institute on Drug Abuse, Bethesda, MD, USA
bBritish Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BC, Canada
cNational Taiwan University College of Public Health, Taipei, Taiwan
dNational Center for AIDS/STD Control and Prevention, China CDC, Beijing, China
eCenter for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung City, TaiwanKeywords:
HIV
Retain
Seek
Test
Treat* Corresponding author. Director of AIDS Re
Bethesda, MD 20892, USA.
E-mail address: jnormand@nida.nih.gov (
1021-9498 Copyright ª 2013, Food and Drug Ad
http://dx.doi.org/10.1016/j.jfda.2013.09.020a b s t r a c t
The “HIV: Seek, Test, Treat, and Retain” session was chaired by Dr Jacques Normand, the
director of AIDS Research at the US National Institute on Drug Abuse. Dr Yi-Ming Chen
served as the discussant. The three presenters (and their presentation topics) were: Dr Julio
Montaner (Treatment as PreventioneThe Key to an AIDS-free Generation), Dr Chi-Tai Fang
(Population-level Effect of Free Access to HAART on Reducing HIV Transmission in Taiwan),
and Dr Zunyou Wu (Challenges in Promoting HIV Test and Treat Strategy in China).
Copyright ª 2013, Food and Drug Administration, Taiwan. Published by Elsevier Taiwan
LLC. Open access under CC BY-NC-ND license.1. Introduction Columbia Centre for Excellence in HIV/AIDS. In his talk, DrTo eliminate the global HIV/AIDS epidemic, there is a need to
promote the “seek, test, treat, and retain” (STTR) strategy [1].
STTR involves reaching out to high risk, hard to reach drug
abusing groups who have not been recently tested for HIV
(seeking), engaging them in HIV testing (testing), initiating,
monitoring, and maintaining treatment for those testing
positive (treating), and retaining patients in care (retaining).2. Presentations
2.1. The British Columbia, Canada, experience
Dr Montaner is a Professor of Medicine at the University of
British Columbia (UBC) and is the Director of the Britishsearch Program, Nationa
J. Normand).
ministration, Taiwan. PublMontaner showed data from a series of studies demon-
strating that the use of highly active antiretroviral therapy
(HAART) has led to dramatic decreases in morbidity and
mortality among HIV-infected individuals. Further, HAART
can prevent HIV transmission among injection drug users
(IDUs), as validated within the ALIVE cohort in the United
States, and as evidenced by a > 65% decrease in HIV new
diagnoses in BC between 1996 and 2010. Recently, the
HPTN052 clinical trial showed a 96.3% decrease in the risk of
HIV transmission with immediate application of HAART, a
41% decrease in disease progression and death, and an 83%
reduction in the incidence of tuberculosis. In Canada, the BC
government implemented an initiative known as Seek and
Treat for Optimal Prevention of HIV/AIDS in BC (STOP HIV/
AIDS in BC) in 2009, and as a result, morbidity, mortality,
and new HIV diagnoses have continued to decrease steadilyl Institute on Drug Abuse, 6001 Executive Boulevard, MSC 9581,
ished by Elsevier Taiwan LLC. Open access under CC BY-NC-ND license.
j o u r n a l o f f o o d and d r u g an a l y s i s 2 1 ( 2 0 1 3 ) s 4es 6 S5in BC. Dr Montaner concluded that expanding access to
HAART is a key strategy in moving toward an AIDS/HIV-free
generation, but the necessary political will needs to be
secured to implement the strategy on a global level, in order
to fully capitalize on the promise of HIV treatment as pre-
vention. Details of this presentation can be found in the
article by Hull and Montaner [2] included in this special
issue.2.2. The Taiwan experience
Dr Chi-Tai Fang is an infectious diseases epidemiologist at the
National Taiwan University College of Public Health. Dr Fang
stated that both HIV infection and AIDS became reportable
diseases in Taiwan in 1984. Taiwan established a nationwide
surveillance system for HIV infection in 1989 and adopted a
policy to provide all HIV-infected citizens free access to
HAART since 1997. By the end of 2002, the cumulative number
of HIV-infected citizens in Taiwan reached 4390 (0.019% of the
total population). Dr Fang’s research team applied an expo-
nential model of HIV epidemic evolution to the national HIV
surveillance data (1984e2002), in order to estimate the HIV
transmission rate [3]. After the implementation of universal
access to HAART, the estimated HIV transmission rate
decreased by 53% (0.391 vs. 0.184 new cases per prevalent
case-year; 95% confidence interval: 31%e65%). Thus, the study
concluded that providing universal access to HAART contrib-
uted to the control of the HIV epidemic in Taiwan. This study
findingwas subsequently validated by DrMontaner in BC, was
cited by the World Health Organization as supportive evi-
dence for scaling up global HIV treatment, and became the
basis of the current “treatment as prevention” paradigm.
While universal access to HAART can reduce HIV trans-
mission, Dr Fang cautioned that it is not a substitute for safer
sex and harm reduction services. HIV epidemics can be
effectively reversed and controlled with the combination of
providing universal access to HAART and harm reduction
services.2.3. The China experience
Dr Zunyou Wu is the director of the National Center for AIDS/
STD Control and Prevention, China CDC, and an adjunct Pro-
fessor of Epidemiology at UCLA. In his talk, Dr Wu stated that
due to a large-scale HIV testing campaign that started in China
in 2004, the number of people being tested for HIV has
increased significantly from23million in 2007 to 101million in
2012, and the number of newly identified HIV cases has
increased from 48,074 to 82,434. However, the number of HIV
cases identified still account for< 50% of the total existing HIV
cases. Further, about one-third of those individuals were
identified at a late stage (CD < 200 at the first time of HIV
diagnosis) and had been infected over 5 years. Meanwhile, the
number of AIDS-related deaths continues to be high (about
20,000 per year). Starting in 2011, China has taken further bold
steps to promote HIV testing and treatment, with targets set
for each province across the nation. This effort has signifi-
cantly improved the identification of infected individuals, and
the number of new patients receiving treatment hasincreased, which should reduce HIV incidence as well as
mortality.
However, there remain several challenges in China.
First, HIV services are not very efficient; < 15% of those
treated achieved viral suppression. Given this low effi-
ciency, it is difficult to achieve the goal of “treatment as
prevention.” Second, even though China has made
considerable efforts in increasing HIV testing, the propor-
tion of people being diagnosed late is still high (e.g., 28% in
2011 and the past year), particularly among those provinces
hit hard by HIV (e.g., Hunan, Quansi), which indicates that
HIV testing services are not adequate. Third, given the low
coverage of IDUs, they have very high mortality rates. Now,
China is at a crossroads of HIV treatment policy, with three
potential choices for providing treatment for: (1) CD4 < 350,
and all pregnant women (regardless of CD4 level), and
discordant couples (regardless of CD4 level); (2) all of the
groups in Choice 1 plus high-risk groups; and (3) universal
or all cases. However, treatment takes considerable re-
sources. The current debate is moving from Choice 1 to 2,
but not Choice 3 yet. Therefore, continued advocacy is still
needed.
Dr Yi-Ming Chen is the vice president and director of the
Center for Infectious Disease and Cancer Research of Kaoh-
siung Medical University in Taiwan. Dr Chen commented
that in addition to HIV testing and identification, risk factors
for HIV infection should also be investigated. After an indi-
vidual has been identified as being HIV-positive, counseling
and partner notification should be considered to prevent
further HIV transmission. Dr Chen offered additional infor-
mation on HIV virus research in Taiwan, mostly based on
molecular epidemiological studies conducted by his research
team.3. Discussion
In the discussion session, there was some dialogue on the
importance of specifying the status of IDUs (active, in treat-
ment, etc.), as well as the importance of considering geno-
type and viral load (e.g., these genetic data are important for
understanding the social context and viral context, as
opposed to putting people in specific boxes). A point was
made about the defunding of HIV prevention efforts in many
parts of the world, because HIV infection and progression to
AIDS has been reduced and therefore is considered a less
urgent matter by policymakers. The question is how to
continue the funding in order to sustain these efforts. In
Canada, efforts are needed to change the defunding problem.
In China, funds for AIDS areas increased slightly this year,
but the number of cases enrolled for antiretroviral therapy is
huge, which consumes a considerable amount of the fund-
ing, resulting in reduced funds for education and other pro-
grams but not the harm reduction programs. In Taiwan,
studies on harm reduction programs provided evidence of
their cost-effectiveness. Therefore, the funding for HIV/AIDS
has not been reduced. It was concluded that joint efforts to
pool resources to continue funding streams should be
considered.
j o u r n a l o f f o o d and d ru g an a l y s i s 2 1 ( 2 0 1 3 ) s 4es 6S6r e f e r e n c e s
[1] Volkow ND, Baler RD, Normand JL. The unrealized potential of
addiction science in curbing the HIV epidemic. Curr HIV Res
2011;9:393e5.[2] Hull M, Montaner J. HIV treatment as prevention: The key to
an AIDS-free generation. J Drug Food Anal.
[3] Fang CT, Hsu HM, Twu SJ, et al. Decreased HIV transmission
after a policy of providing free access to highly active
antiretroviral therapy in Taiwan. J Infect Dis 2004;190:
879e85.


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