Bloomberg Editorial: After 30 Years of AIDS, Push Harder for HIV Prevention

via Bloomberg

AIDS has been with us, officially, for 30 years, since the U.S. Centers for Disease Control and Prevention reported the first cases. This unhappy anniversary is perhaps as good a time as any to spell out why the global response to AIDS is in need of serious adjustment.

Annual spending on AIDS worldwide has risen to $15.9 billion. The bulk of this money goes to the treatment and care of indigent people who are HIV-positive. Without question, the investment in anti-retroviral therapy, or ART, has saved lives. Today, the treatment is provided to about 36 percent of those in the developing world who qualify for it under World Health Organization guidelines.

United Nations member states have pledged to raise that to almost 100 percent. Universal treatment has become the principal mission of many AIDS organizations around the world; governments and philanthropies have followed their lead.

The idea of treating everyone who has the human immunodeficiency virus, regardless of ability to pay, is laudable. The problem is, the laudable runs the risk of crowding out both the practical and the doable. As programs for treatment have grown, those focused on prevention have languished or gotten short-shrift.

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Lancet: Towards an improved investment approach for an effective response to HIV/AIDS

via The Lancet

Summary

Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. We propose a strategic investment framework that is intended to support better management of national and international HIV/AIDS responses than exists with the present system. Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission. It proposes three categories of investment, consisting of six basic programmatic activities, interventions that create an enabling environment to achieve maximum effectiveness, and programmatic efforts in other health and development sectors related to HIV/AIDS. The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion. Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.

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The end of AIDS? Are We There After 30 Years?

Thirty years on, it looks as though the plague can now be beaten, if the world has the will to do so...

via The Economist

Excerpt:

If AIDS is defeated, it will be thanks to an alliance of science, activism and altruism. The science has come from the world’s pharmaceutical companies, which leapt on the problem. In 1996 a batch of similar drugs, all of them inhibiting the activity of one of the AIDS virus’s crucial enzymes, appeared almost simultaneously. The effect was miraculous, if you (or your government) could afford the $15,000 a year that those drugs cost when they first came on the market.

Much of the activism came from rich-world gays. Having badgered drug companies into creating the new medicines, the activists bullied them into dropping the price. That would have happened anyway, but activism made it happen faster.

The altruism was aroused as it became clear by the mid-1990s that AIDS was not just a rich-world disease. Three-quarters of those affected were—and still are—in Africa. Unlike most infections, which strike children and the elderly, AIDS hits the most productive members of society: businessmen, civil servants, engineers, teachers, doctors, nurses. Thanks to an enormous effort by Western philanthropists and some politicians (this is one area where even the left should give credit to George Bush junior), a series of programmes has brought drugs to those infected.

The result is patchy. Not enough people—some 6.6m of the 16m who would most quickly benefit—are getting the drugs. And the pills are not a cure. Stop taking them, and the virus bounces back. But it is a huge step forward from ten years ago.

What can science offer now? A few people’s immune systems control the disease naturally (which suggests a vaccine might be possible) and antibodies have been discovered that neutralise the virus (and might thus form the basis of AIDS-clearing drugs). But a cure still seems a long way off. Prevention is, for the moment, the better bet.

There are various ways to stop people getting the disease in the first place. Nagging them to use condoms and to sleep around less does have some effect. Circumcision helps to protect men. A vaginal microbicide (none exists, but at least one trial has gone well) could protect women. The new hope centres on the idea of combining treatment with prevention.

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What's preventing prevention?

How national AIDS responses are failing in prevention efforts for key populations – an analysis of available data

via International HIV/AIDS Alliance

Several decades after the start of the global AIDS pandemic, data confirms that most low- and middle-income countries still do not adequately focus their HIV prevention efforts on the key populations of sex workers, men who have sex with me, transgender people, and people who use drugs.

Of all low- and middle-income countries that report standard information to the United Nations on their AIDS responses, more than half fail to include timely data concerning these key populations.

According to the International HIV/AIDS Alliance, which has conducted a review of 132 country reports, this is a strong indicator of the current level of national AIDS efforts devoted to reaching populations that are most affected by HIV.

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[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Lifelong Antiretroviral Therapy Unsustainable, Experts Say; One-Time HIV Treatments Must Replace ART

via Medscape Medical News, by Robert Lowes

Although more HIV-infected individuals are receiving life-saving antiretroviral therapy (ART) 30 years after AIDS was identified, researchers must also find cures and vaccines to eliminate the need for this lifelong and challenging treatment, according to an article published online May 31 in the Annals of Internal Medicine by 2 leaders of the National Institute of Allergy and Infectious Diseases (NIAID).

Carl Dieffenbach, PhD, director of the NIAID Division of AIDS, and NIAID director Anthony Fauci, MD, write that lifelong, daily-dosage ART is not a sustainable strategy in a world where 2.5 million people become infected with HIV each year.

To help them stick to their drug regimen, patients receiving ART require a healthcare system capable of delivering long-term care similar to the model used in the United States to manage patients with diabetes.

In an obvious nod to developing nations ravaged by HIV, the authors write that the need for long-term care creates a formidable challenge for "resource-limited settings and for patients who lack adequate health care coverage." They note that ART is given to only 1 in 3 HIV-infected individuals in the world who need it.

Cure Possibilities

One solution, write Drs. Dieffenbach and Fauci, is devising a 1-time cure for HIV, which could fall into 2 different categories. Researchers could find a true "sterilizing" cure that completely eradicates the virus from the body or a "functional" cure that permanently suppresses the virus to a harmless level.

In the case of a sterilizing cure, researchers must solve the problem of cells remaining latently infected even though ART has reduced blood levels of HIV to near zero. When ART ends, these latently infected cells cause the infection to recur.

Investigators are experimenting with ways to flush out the virus from "this persistent reservoir" so it can be treated with ART. Key to the success of this strategy is the development of a simpler, more accurate way of measuring the latent HIV reservoir.

Despite its treatment limitations, ART nevertheless promises to play an important role in preventing HIV infection through preexposure prophylaxis (PrEP) and treatment-as-prevention, according to Drs. Dieffenbach and Fauci. They point to the CAPRISA 004 trial, in which a vaginal gel containing tenofovir lowered the risk for HIV infection in sexually active women by 39%.

Likewise, the iPrEx study showed that a daily regimen of emtricitabine, 200 mg, and tenofovir disoproxil fumarate, 300 mg (Truvada, Gilead Sciences), was 44% effective in preventing infection in men who have sex with men and in transgendered women. The risk for infection decreased by 73% in those who took their pills on 90% or more of the days in the study.

Cautious Optimism

An example of treatment-as-prevention, not discussed in the article, is a recent trial showing that ART given to a group of HIV-infected individuals — most of whom were heterosexual — with relatively healthy immune systems was 96% effective in preventing infection in their partners.

The "ideal cornerstone" of a prevention strategy, the authors write, would be a safe and effective vaccine. The quest for such a vaccine has met with repeated failures, although several recent advances have led to "a degree of cautious optimism." For example, researchers have found that sexual transmission of HIV often appears to begin with a single "founder virus" that differs from the various strains that develop over time in an infected person.

This insight may create new targets for vaccines. In addition, a 2009 vaccine trial in Thailand reported 31% efficacy in preventing HIV infection — a modest success that future trials can build on.

A vaccine that guards against all forms of sexual transmission — including blood-borne transmission — would work in tandem with a growing number of other evidence-based prevention strategies ranging from PrEP to adult male circumcision, according to Drs. Dieffenbach and Fauci.

"Researchers are unlikely to achieve transformative successes in HIV with a unidimensional approach," they write. "Instead, this will require various versions of combination prevention strategies, depending on the target population."


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