We have often observed how DREAMs’ success has always been associated to its capacity to demonstrate that in Africa, even in the poorest, suburban and inaccessible quarters, it is possible to carry out a qualitative diagnose and to provide treatment of excellence. Source of additional satisfaction today is seeing the program managed predominantly by a young generation of African doctors and technicians, of activists and educators, all trained during 9 years of intense and serious work.
However, the skeptical could still claim that, despite the immeasurable efforts carried out, the deep ocean of the epidemic has barely been tapped, surely without having been able to touch its mass and depth, thus without having managed to produce a proper and true perspective of solution for the struggle against the HIV virus. For example, the latest available data from UNAIDS (December 2008), still underlines a substantial growth of cases of living HIV infected in the world, due to the outstrip of the number of new cases of the disease against the number of the deceased due to the same reason.
It is obvious that such balance between deaths and new cases would only perpetuate indefinitely the pandemic. The economic crisis and the lack of tangible signs of reversal of the epidemic trend does not encourage donors, governments and large international agencies and even allow to predict possible failures in the international network of support.
Are therefore the skeptics correct? Should we surrender to an indefinite, pending magic bullet produced by the research? Today DREAM can count upon reasonable grounds in support of a completely different perspective.
First of all, the fact that the considerable results of the program in the field of mother to child transmission of the infection, which has been the subject to a substantial number of scientific publications in major international journals, have been strengthened overtime by many other similar respected studies. It is by now widely confirmed that it is possible to reduce to zero the transmission to the newborn and the infant, thanks to the drugs administered during pregnancy and lactation. The pioneering approach of DREAM has set all the premises and inspired a radical change in the guidelines of the World Health Organization concerning this specific subject and today, with great joy we see a very strong, objective approach to health policies of single African countries with regards to the triple therapy during pregnancy and lactation.
The authority of DREAM is embodied also in the fact that countries like Kenya, Republic of Guinea, Malawi and others regularly involve members of the program in high-level political, technical and decisional meetings, to outline the broad health policies in their respective contexts.
If properly supported, these efforts will lead to a first major victory in the long term, represented by the substantial felling of the infection in newborns and infants. This goal is highly significant if we consider that as of today, in sub-Saharan Africa alone, each year the pregnancies of women infected by HIV amount to 1,3 million and at least 300,000 infants are affected by the disease.
Yet there is a “second front line of hope” towards which we are all currently committed to, a front line which deserves a brief premise: in DREAMs “genetic” it has always been kept in mind the idea that the antiretroviral treatment constitutes in itself, with its potential to eliminate the virus from the plasma and from all body fluids, the real and effective prevention which reduces drastically the infectiousness of those affected by the virus.
In a nutshell, to eliminate the virus almost totally from the body of an infected person means, in a similar measure, to reduce equally the possibility for this person to infect other people. In the last years we have observed numerous direct and indirect confirmation of this thesis: for example, the substantial reduction of the infection within a serum discordant couple, that is, where only one of the two partners is infected: before the introduction of the antiretroviral therapy the negative partner would contract the infection from the positive partner in about 20% of the cases.
After 1996 this share was reduced to less than 3%. In the United States and in Western Europe the number of new cases of the disease has decreased by more than 5 times since the treatment was extended to more than 95% of the infected persons in need of care. On the contrary, in Eastern Europe, where people under treatment are much less than 90% the number of new cases per year is very high and the pandemic tends to grow extremely fast.
In 2009 Granich and other WHO authors proposed a arithmetical model capable to simulate projections of the epidemic trend overtime, taking into consideration the regular access of the entire population to the rapid test for the infection and extended treatment to all infected. The results looked very promising in terms of the reduction of the pandemic and DREAM premises regarding the possibility of reducing to zero the new cases of the disease overtime, are very comforting.
Thus a new dream takes shape, a dream to be implemented in a standard African district with 400.000 inhabitants. In this environment, a regular test of the whole population and the immediate care of all HIV positive will allow, within 3 years, to “sterilize” the epidemic, reducing new cases to zero. Further measures to be carried out could reinforce and stabilize this result overtime. Male circumcision in particular has proved to be an extremely valid precautionary measure, capable to reduce the risk of transmission of 60%. A district would also be the ideal theatre to carry out, jointly with the systematic testing for HIV/AIDS, an extensive health education campaign with the well-known benefits, which have been confirmed over the years. Many other measures, such as the prevention of mother to child transmission, the evaluation and the nutritional supplement, could have a very significant impact both over the state of health of all the components of that specific environment as well as over the defeat of the pandemic.
In short, even if there is still so much to do, our hope continues to grow and finds constantly new confirmations!
 Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model Reuben M Granich, Charles F Gilks, Christopher Dye, Kevin M De Cock, Brian G Williams, Lancet 2009