The Big Read: South African scientists are launching an important HIV clinical trial to confirm the efficacy of a gel that reduces the risk of women getting HIV.

This is the first South African-led consortium to conduct HIV research at seven centres, said the executive director of the Wits Reproductive Health and HIV Institute, Professor Helen Rees.

Until now, multi-site trials were led by international scientists collaborating with local peers.

"The planning for the Facts study is well under way and we hope to be in the field by August," said Rees.

The past year has seen a revolution in HIV-prevention research sparked by three exciting results - one being the gel.

A Tenofovir vaginal gel proved 39% effective at protecting young women from HIV and halved the risk of Herpes HSV-2, according to the Caprisa 004 study in KwaZulu-Natal.

Facts aims to confirm these results.

Until now, the most effective prevention options have been condom use, prevention of mother to child HIV transmission, or PMTCT, medical male circumcision and HIV counselling and testing.

South Africa has made dramatic gains since 2008 in:

• Reducing the number of six-week-old infants infected with HIV from 8% to 3.5% nationally, through its PMTCT programme;
• Expanding medical male circumcision, with 140000 men nationally being circumcised; and
• Expanding access to condoms, with plans to distribute 1billion male condoms and 6million female condoms this year.
• About 12million South Africans were tested for HIV since April last year.

Department of Health deputy director-general Dr Yogan Pillay said: "We are doing a lot . [but] our results are very mixed. We need to do more targeted prevention."

The old slogan for prevention "ABC - abstain, be faithful and condomise" - is inadequate for South Africa's HIV epidemic.

For example, married women may get HIV from unfaithful husbands who refuse to wear condoms with them.

Professor Salim Abdool Karim, director of the Centre for Aids Programme Research in South Africa, said: "The tools we have are mismatched for the epidemic. We need women-controlled methods."

Recent studies show HIV-negative women and men can be protected from the virus by antiretroviral drugs. This approach is known as Prep, or pre-exposure prophylaxis. Prep options show potential and will shape the HIV/Aids national strategic plan for South Africa 2012/16.

Rees said: "We need to act on these results, but we also need to build in checks and balances so that the wheels of the fragile healthcare system do not come off.

"The prevention of mother to child HIV transmission is one [established] example of Prep that has been massively effective.

"PMTCT was implemented based on research and successfully integrated into a national programme that has saved hundreds of thousands of children's lives and improved their quality of life."

Rees chaired a discussion at the fifth South African Aids Conference in Durban last week on the "promise and perils" of providing the new forms of Prep in South Africa.

The most promising Prep tools in the pipeline are:

• The Tenofovir vaginal gel, also known as a microbicide;
• Truvada tablets combining two antiretrovirals. These prevented infection in 42% of men having sex with men at high risk of infection (iPrex results released last November); and

• Early initiation of triple antiretroviral drugs by people with HIV. This protected their partners 96% of the time from HIV (HPTN 052 trial results released last month).

Conference delegates debated the next steps on these discoveries.

Young women in their teens and early 20s are at highest risk of HIV.

Men having sex with men, or MSM, who identify themselves as "high risk" would also benefit from an innovative prevention tools.

Rees said: "In South Africa they are reluctant to come forward to health services, except to a few special clinics and pilot sites.

"We need to set up MSM clinics attached to the public sector and train people in MSM sexual health issues. We could try to introduce Truvada in this setting and the men would have to be carefully monitored for uptake, adherence and drug resistance.

"More generally, in the new national strategic plan we need to cater for high-risk groups who do not access mainstream health services, like MSM and sex workers."

Doctors are strongly advocating starting ARV treatment early to avoid infecting sexual partners.

They insist that it will benefit both individual and public health, for example, by reducing TB infections.

Right to Care clinical director Dr Francesca Conradie said: "In terms of interventions, this is hot right now. We should start putting people on treatment when their CD4 count (a measure of their immunity) is up."