The REALITY trials

Reducing deaths among those who seek HIV treatment late. 

Moses arrives in hospital in Malawi after months of suffering terrible headaches. He has made the trek all the way back from Zambia, where he was working. He tests HIV positive, and is found to have a CD4 of only 11, showing that the virus has almost completely destroyed his defence system. He is started on HIV treatment: anti-retroviral therapy (ART). He has a good chance of recovering if only he can get through the first months until the ART kicks in. Unfortunately, people like Moses, who seek treatment late, are the group where most HIV-related deaths occur in Africa. So can anything be done to try to keep him alive long enough for his immune system to build strength?

The REALITY trial was set up to look at different strategies to buy time for people like Moses. It tried giving extra ARVs for a short period to bring down the levels of HIV very quickly. It tried giving extra food to build up weight fast in the first months. But if found that the most significant improvement came from a package of easily available anti-microbial drugs, taken in the first three months to give prophylaxis against opportunistic infections. Researchers are now recommending this “enhanced prophylaxis” package be rolled out to late presenters.

The research also looked into why so many people still seek treatment late. Many did not realise that they were putting themselves in danger by doing this, thinking the right time to get treatment is when you are already sick. Researchers also found that the message of the huge benefits of early ART is not understood at a community level and that there is still a great deal of fear of the side effects and of being identified as HIV positive.