HIV prevention: new pilots for beleaguered Swaziland.

The good news is that the incidence of HIV in the Kingdom of Swaziland has stabilised over the past 5 years. The bad news is that it is still 31% among adults aged 18–49 years and, alarmingly, 43% among pregnant women. All told, an estimated 201 292 Swazis were HIV-positive in 2012, despite intensive eff orts to mitigate the epidemic. The government provides antiretroviral treatment (ART) and, in partnership with various organ isations, is working to decentralise services, ramp up testing and treatment, and, due to a shortage of physicians and nurses, shift tasks to new cadres of health workers. Now the government and nongovernmental organisations (NGOs) are testing a new approach: treat everyone who is HIV-positive, irrespective of viral load, CD4 count, or disease stage, with the aim of preventing the spread of HIV. Currently, in accordance with WHO’s 2010 protocol, only adults with a CD4 count of 350 cells per mm or less are off ered ART. Three implementation studies are slated to launch this year. In February, Médecins Sans Frontières (MSF) will begin off ering ART to all HIV-positive pregnant women in one health zone. In late winter, the International Center for AIDS Programs (ICAP) at Columbia University, NYC, USA, hopes to begin a comparison of two protocols for HIVpositive pregnant women. And as early as mid-2013, the Clinton Health Access Initiative (CHAI) plans to off er ART to all HIV-positive adults at ten sites. Using treatment to prevent HIV transmission has been studied for years, but the turning point came with the August, 2011, publication by Myron Cohen and colleagues on the phase 3 clinical trial, HPTN 052 that showed a 96% reduction in risk of HIV transmission in serodiscordant couples. Minister of Health and Social Welfare Benedict Xaba tells The Lancet “eliminating mother-to-child transmission of HIV by 2015 is the priority in order to ensure an HIV-free generation”.