Treating HIV Sooner Would Save South African Lives and Money

Via Science Daily.

If the South African government followed a recent recommendation by the World Health Organization to start antiretroviral therapy (ART) for HIV-infected residents earlier in the progress of the disease, the policy shift would start saving the country money after 16 years and would extend thousands of lives for dozens of years, according to a new study.

In 2009, the WHO recommended that people start ART when a key measure of immune system strength, the CD4+ cell counts, reaches a concentration of 350 per microliter of blood. South Africa has instead decided to stick with the old standard of waiting until only 200 cells per microliter remain, reflecting a more compromised immune system.

"South Africa, the country with the most people living with HIV/AIDS in the world, has not yet adopted the WHO treatment initiation criteria," said Mark Lurie, a Brown University epidemiology professor and senior author of the study published online July 20 in PLoS One. "We used a mathematical model to predict the impact of adopting the new WHO guidelines on HIV prevalence, incidence, and cost. We found that changing the treatment guidelines would have a profound impact on HIV incidence. It would require, over five years, an additional 7 percent investment, resulting in 28 percent more patients receiving HIV treatment. After 16 years, the cumulative net costs reach a break even point."

In addition, the models developed by Lurie's team show South Africa saving more than 120,000 life-years by 2040. Life-years are determined by multiplying the number of people who will still be alive by the number of years of extra longevity.

The reason why the higher up-front investment in ART ultimately would save South Africa money and lives, the authors wrote, is because more aggressive ART treatment would curb the epidemic's spread. Reduced infectivity from the drugs would outweigh the longer period of time in which HIV-infected people would be alive and therefore able to spread the virus.

Read the rest here.

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

A Trade Barrier to Defeating AIDS

Via the New York Times, by Tina Rosenberg.

Earlier this month, [the Medicines Patent Pool, a new organization trying to make AIDS drugs better, cheaper and available sooner to people who need them in poor countries] received its first donation of rights from a pharmaceutical manufacturer, Gilead Sciences.   It is an important step  — but the terms Gilead negotiated are also confirmation of a dangerous new trend: middle income countries as a target market for drug makers.  In the past, pharmaceutical companies have lowered prices in these countries to increase sales.  The new strategy is to treat people in Egypt, Paraguay, Turkmenistan or China — middle-income countries, all — as if they or their governments could pay hundreds or even thousands of dollars a year each for AIDS drugs.   This low-volume high-profit strategy might make  business sense.   But in terms of the war against AIDS, it means surrender.

In the world’s most impoverished countries, AIDS drugs are cheap.   It wasn’t always that way.  Until well into the Clinton administration, the United States government pressured even the poorest countries shamelessly if they tried to bring down the prices of medicine.   Even newly democratic, AIDS-ravaged South Africa became the object of an all-out assault by the Clinton administration to get the country to repeal a law allowing it to break medical patents, a step that was perfectly legal under world trade rules.  Washington was not interested in the health consequences.   (A U.S. trade negotiator who worked on South Africa at the time told me that he had been unaware that AIDS was a major problem there.)    Public outrage over South Africa ended Washington’s pressure on poor countries.   In 2000, President Clinton issued an executive order pledging that sub-Saharan African countries would not face trade sanctions for laws promoting access to AIDS medicines.

The order continues to be largely respected, and the group of countries who are generally able to get access to the cheapest drugs has grown to include the poorest countries from around the world — Afghanistan, Tajikistan, Bangladesh, Burma.    Gilead’s agreement with the Medicines Patent Pool covers these countries.

But countries just above this cutoff line are on their own.  “There are countries that are considered to be “middle income” that will never be able to afford the high prices charged by innovative pharma companies,” said reader A. Grant of New York.  These nations are also losing the discounts that major manufacturers of AIDS drugs used to offer them.  According to Médecins Sans Frontières, which tracks drug prices, prominent manufacturers of AIDS drugs have stopped offering discounts to middle-income countries, or now require that countries negotiate those discounts one by one.

Read the rest here.

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

HIV Prevention and LGBT Communities: Syndemics, Resilience, and Real Change

How can justice be better served for the lesbian, gay, bisexual and/or transgender (LGBT) community? This remains one of the biggest questions in the US – the last few months have seen a country-wide discussion on this issue, sparked off by what is being called an “epidemic” of suicides by gay teenagers.[1] “People are talking about the important ways through which the US, in the coming generation, can begin to honor the rights of LGBT communities – I believe, in time, that would reduce the incidence of HIV infection,” says Julie Davids, Director of National Advocacy and Mobilization at the AIDS Foundation of Chicago and Coordinator at the HIV Prevention Justice Alliance.

There is strong data on the “syndemics” phenomenon[2] (synchronous epidemics) in the lives of gay men. Gay men often face violence, abuse, marginalization and rejection by parents, friends and peers – there is compelling data that these conditions make them far more vulnerable later in life to substance use and abuse, intimate partner violence, and contracting HIV. The syndemics discussion has also led to an increasing focus on the idea of resilience. Says Julie, “Although HIV is very widespread among gay men, the majority of gay men are not HIV positive – what helps them remain HIV negative? As someone who believes very strongly in the idea of gay and queer liberation, I believe that members of LGBT communities create resilience, have innovative ways of living and of structuring families and lives that can be extended to broader society for better health outcomes and happier lives.”

There is a concerted effort to steer prevention efforts away from an earlier reliance on fear tactics and a vocabulary based on vulnerability. The gay men’s health movement and their allies in the HIV/AIDS community are increasingly emphasizing resilience and trying to create a scale of measuring this quality in the lives of gay men – and hopefully extend this to other communities as well. “There are a number of programs – like Project CRYSP, Lifelube, the Gay Men’s Health Crisis, and the Gay Men's Health Summit – that confront the conditions that drive the syndemic among gay men and build resilience and resourcefulness in gay communities[3]. Other projects doing fantastic work in this field include the Gay City Health Project in Seattle, Magnet in San Francisco, and William Way in Philadelphia,” says Jim Pickett, Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago, chair of IRMA, and a member of the Mapping Pathways team. In fact, Jim recently checked in with Dr. Ron Stall, an expert in gay men’s health, to get his views on syndemics and the HIV/AIDS epidemic among gay youth and adults, as well as the idea of resilience. You can read the eye-opening interview here.

The approach to HIV prevention could also benefit from elements of asset-based community development: focusing on the assets of a community, the skills and experiences that are available, can help illuminate the path forward and create sustainable solutions.

“We can’t do it all on our own though,” says Julie, “so it’s important to continue to push for government policies that honor the human rights of all people – specially now that there is a focus on the impact of bullying of LGBT people. We need to made sure doesn’t just end up contributing to mass imprisonment – another social driver of HIV in our country. Creating merely a punitive system doesn’t really solve the problem – it just results in more imprisonment, thus exacerbating health issues like HIV. Many people who are bullies have been bullied themselves. We need policies and mechanisms to increase parental acceptance of gay and gender variant children, strengthen communities to support all their LGBT members rather than rejecting them, and help people proactively stand up to bullying. Addressing the root causes will bring about real, long-term change.”

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[1] To know more, take a look at The New York Times’ “Coming Out” project, which captures compelling first-person accounts by gay teenagers.

[2] Syndemics: A set of linked health problems involving two or more health conditions, interacting synergistically, and contributing to excess burden of disease in a population. Learn more about the syndemic among gay men that drive the HIV/AIDS epidemic by accessing Ron Stall’s presentation here.

[3] Take a look at Jim Pickett’s presentation on this here.

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

Treatment As Prevention: We Urgently Need Policy Guidance

Via PLoS, by Nathan Ford.

The International AIDS Society conference on HIV Pathogenesis, Treatment and Prevention in Rome has been hailed as a landmark conference for HIV prevention. Just as the AIDS conference in Vancouver in 1996 marked the beginning of the international effort to roll out antiretroviral therapy globally, so Rome will likely be remembered as the beginning of a new era in biomedical prevention.

The results of the HTPN 052 discordant couples trial, which found the greatest incidence reduction of any prevention intervention evaluated to date, were met with a standing ovation. This trial found a 96% reduction in HIV transmission and a 40% reduction in serious complications, in particular tuberculosis (TB), among patients starting ART early, at CD4 350-550 cells/mm³.

Implementation of this strategy is, however, hampered by lack of guidance from the World Health Organization. Draft guidelines for the provision of ART in discordant couples have been in process for many months, and their release was first announced in May, and then again July. However, by the end of the conference it remained unclear when the guidelines would be released, or what they would say.
Rumours spread in the conference corridors that WHO had been pressured to delay the release. Some suggested the issue at stake was to find the right balance in investment between the results of HTPN 052 and those of the recently completed pre-exposure prophylaxis trials that also reported a substantial prevention benefit.

There are at least three reasons why such a trade off is wrong.

First, providing ART earlier is desirable for more reasons than reduced HIV transmission: the HIV-positive individual receives treatment at a stage in their disease that developed country guidelines already consider therapeutically beneficial; their risk of developing incident diseases, in particular TB, is substantially reduced; reducing TB incidences confers the additional public health benefit of reducing the risk of TB transmission.

Second, discussions about whether to give ART to HIV-positive or HIV-negative individuals are ethically problematic. Economics has long been described as the ‘dismal science’, but it is hard to think of a more dismal economic proposition than to delay giving ART to people already infected with the pathogenic HIV virus in order to give the drugs to HIV-negative individuals instead.

Third, there are fundamental practical differences to the two approaches. Implementing the results of HTPN 052 means further extending what is already happening (giving ART to HIV-infected individuals); in contrast, giving ART to HIV-negative, at-risk individuals requires extensive operational research to help define what is essentially an entirely new programmatic approach.

Read the rest here.

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

From 'what if' to 'what now': implementing the new prevention technologies

Via AIDSMap, by Gus Cairns.

 

Two consecutive sessions at the sixth International AIDS Society conference in Rome yesterday were devoted, now we have convincing scientific data on the benefits of treatment as prevention and PrEP, to putting these new prevention methods into practice.

“We have moved from ‘What if?’ to ‘What now?’” was the comment of Mitchell Warren, Executive Director of the AIDS Vaccine Advocacy Coalition (AVAC), on what else we need to know, what barriers need to be addressed , and what resources might be required, to maximise the promise of antiretroviral-based prevention.

Anthony Fauci, Director of the US National Institute of Allergies and Infectious Diseases (NIAID), said: “We now have a solid scientific foundation to say that even in the absence of a vaccine we have the capacity to end the epidemic. I can’t go to the US President and say: 'We can cure HIV.’ But I can say ‘Ending the epidemic is scientifically doable’.”

Earlier, however, Nancy Padian from the Office of the US Global AIDS Coordinator had outlined formidable challenges still to be answered if antiretroviral treatment could bring about this goal.

She said that questions still needing answers include whether antiretroviral drugs (ARVs) really are a durable and reliable means of viral load suppression over a period of years and whether increasing the proportion of people on treatment would lead to increased levels of resistance. The biggest practical question, however, was whether treatment as prevention would work in situations where a high proportion of transmissions came from people with acute, recent HIV infections.

The biggest barriers to treatment as prevention, however, are stigma and lack of resources. Implementing ARV-based prevention would not only be expensive in terms of drugs; it would require added human resources and increased training and task-shifting for prevention counsellors so they can deal with biomedical data. There would also be added costs in terms of tests and monitoring.

The other big barrier will be the stigma of being tested, she said, particularly for at-risk populations in societies where injecting drug use, male-male sex, or sex work were criminalised and stigmatised. Treatment as prevention would require people not simply to test and then go to more supportive community organisations for prevention advice; it required a much closer relationship with medical personnel who might be prejudiced or feared to be so.

Mitchell Warren issued a call to action to implement the new strategies, but his presentation was tempered by realism. “We have evidence, we have data, and we now need to make decisions,” he said.

Read the rest here

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