In the light of current enthusiasm for 'treatment as Prevention (or 'is' prevention or some other permutation)', it's sobering to read an article from the US entitled 'Only 28% of HIV patients have condition under control'. The idea of treatment as prevention, sometimes referred to as 'test and treat', is that it will be feasible to test about 80% of an entire population, not just once in a while, but regularly, perhaps once a year or more. Upon being found Hiv Positive people will receive immediate treatment, regardless of clinical stage.The US spends over $7,000 per capita according to WHO estimates for 2009; that's over 15% of GDP. Tanzania, in contrast, spends $57 per capita, 4.5% of GDP. So if only 28% of HIV positive people in the US are rendered unlikely to transmit the virus to others through having a low viral load, at least through (safe heterosexual) sex, and about 20% of those infected don't even know they are positive, where does this leave countries like Tanzania?Figures for how many Tanzanians are on antiretrovirals vary a lot and are vague; they don't make it clear what percentage on treatment have the virus under control. Quite a lot of people said to be on treatment are lost to follow-up every year. Many die or move to another area, but this also suggests that numbers on treatment are overestimated as some are registered in more than one place. The majority of HIV positive people in Tanzania are not on treatment and a majority of the population have never been tested for HIV. A large number of people who have never been tested are estimated to be HIV positive.I just don't feel convinced that the money is going to be stumped up to test tens of millions, perhaps hundreds of millions of people every year for the foreseeable and to treat tens of millions for several decades to come. But perhaps I'm just a sceptic (or 'skeptic' if you're in the US).Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. read more..
Tuesday, 20 March 2012
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Wednesday, 29 February 2012
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It's a relief to hear that there are some people working with HIV who are willing to speak out against the apparent assumption that treatment is Prevention, that all we need to do is substantially increase the number of people taking expensive antiretroviral therapy (Art) for the rest of their lives, regardless of the known consequences of such a strategy, and HIV transmission will magically decline and eventually disappear.Alison Rodger, Andrew Phillips and Jens Lundgren recommend that before adopting ART as a prevention policy, we need to assess the risk of HIV transmission through unprotected sex (ie, without a condom) when the viral load is undetectable. So far, research has revealed that transmission could be unacceptably high under such circumstances, but neither the media nor the academic hype around treatment as prevention has alluded to this.Xiaohua Tao, Dan Shao and Wei Xue call for an assessment of how a policy of treating HIV positive people at an earlier stage of disease progression would affect their sexual behavior. They point to evidence that use of ART increases risky sexual behavior. They also express worries about the development of resistance to ART, which is one of the known consequences alluded to above.Enthusiasts of the treatment as prevention strategy, Myron S. Cohen, Ying Q. Chen and Thomas R. Fleming, accept that the benefits of ART are unknown where condoms are not used as part of the strategy. They also note the frequent occurrence of pregnancy and sexually transmitted infections (STI) among trial participants, which suggests that self-reported sexual behavior was not so accurate, or that condoms are a lot less effective in reducing STI transmission and pregnancy than we are led to believe.Essentially, Cohen and colleagues are a bit vague with one of the real worries about a treatment as prevention strategy: the lack of clarity about how HIV is transmitted so rapidly in only some countries. The orthodox view is that heterosexual sex is responsible for 80-90% of transmission. But why should a virus that is difficult to transmit through penile-vaginal sex be transmitted so rapidly in certain populations? Do they all secretly engage in anal sex? Or are there non-sexual risks that some of them face?Uganda is an interesting case in point. The orthodoxy gather up lists of 'most at risk' people, men who have sex with men, intravenous drug users and the like. They also add in sex workers, truckers and other groups who are said to be vulnerable because of their 'mobility', whatever that may mean. But there is always the assumption that heterosexual sex is the key. Yet none of these circumstances explain massive rates of transmission in some countries, where most people don't fall into any of those groups said to face high risks.Indeed, the majority of transmissions in Uganda and other countries are among people who do not face high risks, they fall into low risk categories, even by the strictures of UNAIDS and others in the industry. Don't these astute people notice the contradiction in their claims, that most HIV transmission occurs among low risk people, those who do not have high risk lifestyles? What is it about Ugandans? Is it their sex lives, their sex organs, or something else?It's not just treatment as prevention or any other smug strategy that will fail if we don't make it clear how HIV is being transmitted, why it is being transmitted amongst people whose ostensible risk behavior levels are low and why doling out ever increasing amounts of drugs to ever increasing numbers of people should make any difference; because, so far, for every person put on drugs, two become newly infected. If putting 6 or 7 million people on ART doesn't reduce transmission, why should doing so with 16 or 17 million, or more?Treatment is not prevention and until the actual modes of transmission, rather than assumed modes of transmission, have been properly assessed, HIV prevention efforts in Uganda and el read more..
Thursday, 23 February 2012
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Pre-exposure prophylaxis (PrEP) is an experimental method of HIV prevention. It involves a doctor prescribing antiretroviral HIV/AIDS drugs to a healthy person in order to prevent that person from possibly getting infected with HIV. So far, clinical trials have failed to prove PrEP’s effectiveness… (Click below to read more.)The 2007 iPrEX study found that PrEP reduced the risk of HIV infection among men who have sex with men (MSM) by only 44%. A part of the 2009 Vaginal and Oral Interventions to Control the Epidemic (VOICE) study was discontinued two years later because tenofovir (branded as Viread by Gilead Sciences) tablets were no better than a placebo in protecting HIV-negative women from HIV. Researchers stopped another trial in 2011, called Fem-PrEP, after they concluded that Truvada (Gilead’s combination tablet of tenofovir DF and emtricitabine) was unlikely to prevent HIV infection in women. Partners PrEP, a study of sero-discordant couples in Africa, showed an efficacy rate of 62%-73%. However it is imprudent to extrapolate the overall effectiveness of PrEP based of this study since the researchers reported an adherence rate of 95% among the study participants — a figure that would likely be much lower under non-clinical trial conditions and as a result, would likely lead to a lower overall efficacy rate.Questionable clinical efficacy aside, a surge in the interest around PrEP is puzzling given that 14.6 million HIV positive people around the world in need of ART right now are not receiving it. Expanding the permitted use of a lifesaving antiretroviral therapy—which is currently unavailable to those 14.6 million individuals still in need of treatment—as a sanctioned form of HIV prevention for use by uninfected individuals presents both a practical and moral dilemma for both Gilead and society at large.In the United States, the Centers for Disease Control and the Federal Drug Administration (FDA) have expressed interest in establishing guidelines for the use of PrEP. Under the current regulations, a medical provider is allowed to prescribe ART to a HIV negative person. This is called ‘off-label use’ – use of an HIV/AIDS medication for purposes other than treatment of HIV— effectively constitutes PrEP. However, as long as PrEP is not officially sanctioned by the FDA, drug companies cannot market ARTs as a preventative measure to the public. If PrEP is eventually approved by the FDA, pharmaceutical companies stand to make a lot of money catering to a new market in the developed world instead of providing cheaper—and much needed—drugs in the developing world.Internationally, PrEP has also received attention from the EU, the World Health Organization and various civil society organizations and advocates in the global health arena. The fact that PrEP is being considered as an evidence-based HIV prevention approach is incomprehensible at a time when the world cannot treat all people with HIV who are already ill.With the continued assault on generic drug manufacturers by Big Pharma and a stagnating commitment by the rich countries to contribute more money to the global AIDS fight, PrEP looks more like a pharmaceutical cash cow in the making, than a viable or prudent public health initiative. In the United States, one year of ART can cost upwards of $10,000 USD. Currently, there are waiting lists in the US for HIV-positive low-income people in need of treatment. In Eastern Europe, Central Asia and Africa ART coverage remains unacceptably low and far behind the Universal Access target of 80% for all who need it. Is it possible to justify giving PrEP to healthy people while the sick and dying are waiting for treatment?The legitimization of PrEP is detrimental because it could lead to a false sense of security among people who are currently using condoms to protect themselves. To achieve even a modest level of protection, PrEP requires strict adherence to a daily ART regime read more..