Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

31 May 2011

Metaphors of HIV Prevention : 1. The HIV Prevention Buffet

via Incidence0, by Roger J. Tatoud

In the very early years of the HIV epidemic, as it was becoming clearer that the virus was mostly sexually transmitted, HIV prevention was limited to promoting condom use. For years, that was all that was available to protect oneself whilst politicians were debating the threat and relevance of this new disease, if they were talking about it at all. Then as the disease spread and a new kind of activism was able to draw more attention to what was becoming an epidemic of epic proportion, it became evident that more needed to be done and from limited, HIV prevention became simple as ABC.

ABC soon revealed its limitations. Abstinence never worked for very long, nor did faithfulness, and as for condom, 30 years of the same repetitive message led to a general fatigue. Still, in 2002, behavioural changes – such as the ABC approache, was accepted as key to understanding and combating the sexual transmission of HIV and confirmed as the way forward for HIV prevention.

Came 2008, when it was finally recognised that ABC was simplistic and was failing to achieve notable and sustainable results. Then, Richard Horton wrote in a Lancet editorial “We need combined prevention, including a portfolio of biomedical, behavioural, and structural interventions”.

Combination Prevention is the new metaphor that will be pervading the field for years to come. But to have substance and impact the approach needs to figure out what to combine. Structural interventions are quite straightforward to identify thought far less to implement (e.g. MSM have finally been recognised as a “most at risk population” at the Mexico AIDS conference in 2006 but progress in addressing their needs is still very slow. Women’s rights have been on the table since the eary 70s, and we still talk about them). Behavioural changes interventions have been extensively explored and implemented in a broad range of situations but with limited success. To date there are very few successful biomedical interventions and none that can compare with condoms when considering efficacy only. But it is believed that expanding the range of interventions will be key to a successful control of the epidemic

From here there are different ways to work out the role of biomedical interventions in Combination Prevention, and the HIV Prevention Buffet metaphor (a.k.a “fast food” metaphor) is one of them. Though there is not much on the menu of the Prevention Buffet, the story goes like this:

Read the rest.

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

30 May 2011

To PrEP or not to PrEP?

An ongoing development in the PrEP landscape is the AIDS Health Foundation’s (AHF) campaign against Gilead Sciences – more accurately, Gilead Sciences’ pursuit of a new indication for prevention from the  FDA for its “AIDS drug” Truvada. While Truvada is currently approved by the FDA for use as part of antiretroviral therapy combinations for individuals already living with HIV or AIDS, whether the pill should be used as a form of pre-exposure prophylaxis for those not infected is what’s under contention by the AHF.

The Truvada pill, a drug compound that consists of Gilead’s drugs Viread (tenofovir DF) and Emtriva (emtricitabine), was studied in both the iPrEx and FEM-PrEP trials to test its efficacy as a form of treatment as prevention. iPrEx showed this successfully, and FEM-PrEP not so successfully. (Read the Mapping Pathways blog post about this here.)

AHF’s campaign to halt Gilead in its pursuit of FDA approval gained new momentum after the FEM-PrEP trial closure. Read more about the AHF’s thoughts about this here and at

The organisation also recently conducted a survey with 822 men to examine “real world” reactions from prospective consumers about taking PrEP and gauging potential adherence issues. Among the findings: 79% of respondents answered “Yes” to the question: “If you could take a pill on a daily basis to prevent HIV, would you take it?” However, only 63% of respondents said they would be “Very Likely” to remember to take the prevention pill every day. Read more about the survey here.

While no-one is contending that PrEP requires a lot more thought before being rolled out fully, many advocates feel that the AHF’s methods of gathering “real world” information are based on half-truths and stereotypes rather than a solid evidence-base. Read this critical analysis of gaps in the AHF survey here.

All this just confirms the need for a lot more objective information from a variety of sources – communities, academics, policymakers and those infected with HIV – to help us understand the rapidly evolving and dynamic PrEP landscape and the various strategies that can be deployed to prevent and eradicate HIV/AIDS.

Jim Pickett, from the AIDS Foundation of Chicago, a Mapping Pathways partner organization, sums this up best: “This discussion is of the moment, everything has just coalesced now, everything is happening now, and communities across the world are grappling with these strategies, wondering, ‘How in the world do we do this when we have all these other struggles? But on the other hand, how do we ignore it; how can we possibly ignore a new tool that could reduce so much suffering?’ And we have to realize that there are going to be different answers for different places in the world, or even in different parts and populations of one country. We’re hoping that the Mapping Pathways initiative will be able to provide some guidance to help figure all this out. There are so many complex issues to unravel and it is our duty to weed through all of these challenges, all of the promises, and all of the potential perils of these new strategies.”

The Mapping Pathways project is also in the process of trying to gather perspectives on these questions from folks in our current focus areas – the US, South Africa, and India. If you’re interested in new ways to prevent transmission of HIV – and want to help shape our project goals and deliverables – we encourage you to take a few minutes and fill in our survey.

Your efforts will be greatly appreciated!

Take the survey now.

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

26 May 2011

The Lancet: “HIV treatment as prevention – it works”

On May 21, The Lancet published a fascinating editorial on the compelling interim results of the HPTN 052 study, making a strong case for treatment as prevention. The article reinforces the fact that we appear to be on the cusp of a major overhaul with regard to both treatment and prevention. As it points out, “Findings now need to be translated into policy and action. Agencies such as President's Emergency Plan For AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria need to reassess their prevention portfolios and consider diverting funds from programmes with poor evidence (such as behavioural change communication) to treatment for prevention. There is now an ethical imperative for guidelines to be revised to start treatment much earlier than recommended.” Ironically enough, this has happened in the middle of the recession, so chances of procuring the necessary funds seem bleak – at least for the next couple of years.

While it is important to note that the HPTN 052 findings cannot be extrapolated to gay men and other MSM (the small number of gay men in the trial is a definite drawback), it seems reasonable to believe that the impacts would be similarly strong among them. Read the full article here, and tell us what you think!

Also, folks from the US, South Africa and India who are interested in new ways to prevent transmission of HIV – and want to help shape our project goals and deliverables – are highly encouraged to take a few minutes and fill in our survey.

Your efforts will be greatly appreciated!

Take the survey now.

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

23 May 2011

Please take the Mapping Pathways survey and help shape the future of HIV prevention

The Mapping Pathways project has launched on online survey to collect input from individuals in our three target countries - India, South Africa, and the United States.

Folks who are interested in new ways to prevent transmission of HIV - and want to help shape our project goals and deliverables - are highly encouraged to take a few minutes and fill in our survey.

Your efforts will be greatly appreciated!

Take the survey now.

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

22 May 2011

NYT Times: Drugs Stop AIDS. Take Your Medicine.

[There are some problematic assertions that McNeil makes in this article. One is that HIV+ people who choose to not begin treatment are "selfish" and/or "self-destructive." There are many reasons that a person may have to forestall treatment that wouldn't include either of those negative characterizations. Another troubling idea is that people with HIV are somehow incapable of safer sex practices. In fact, most people who know they are HIV+ do practice safer sex. More unsafe sex happens when people do not know their status. There are a number of other problems with this, see what you think - Mapping Pathways]

via New York Times, by Donal G. McNeil Jr.

There is now, for the first time, hard clinical evidence of an effect that AIDS doctors have suspected for years: If you are H.I.V.-positive, being on antiretroviral drugs will probably save not only your life, but also the lives of your sexual partners.

This month, a randomized clinical trial — the gold standard in medical research — showed that the drugs lowered the chances of infecting a partner by 96 percent.

This is good news for the infected and their lovers. But it is a moral dilemma for doctors whose infected patients do not want to start taking drugs immediately, usually because they do not yet feel sick and have heard exaggerated rumors about side effects.

What does a responsible doctor do with a patient who is sexually active and teeming with a fatal and incurable virus? Advise him to use condoms and trust him to act decently? Beg?

Behind each doctor — whose primary duty is to one patient — there is a government public health bureaucracy, whose duty is to protect the whole country. The epidemic has been killing Americans for 30 years now.

Whose rights should be paramount? Those of the patient? Or those of his healthy spouse — or boyfriend, or date, or hookup, or client, or rape victim, or incest target?

This debate has been going on since AIDS began, and has always been inextricably mixed with the circumstances of its birth: it was a sexually transmitted disease that emerged among gay men in the middle of the sexual revolution and the new gay rights movement. AIDS still carries a huge stigma and provokes hatred wildly out of proportion with the fact that it is simply a new virus. (Neither SARS nor H1N1 were called “God’s wrath.”)

But the fact that there is a new form of prophylaxis reopens old questions.

Several AIDS clinicians interviewed for this article said the idea of forcing treatment onto a patient was repulsive to them.

“It was unthinkable when we had this debate in the early 1980s, and it’s unthinkable in 2011,” said Dr. Myron S. Cohen of the University of North Carolina, who led the study that found the 96 percent protection rate. During a long discussion, he called the idea “medieval” and “a violation of civil rights.”

Read the rest.

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

21 May 2011

Drug price cuts secured amid growing funding fears

via PlusNews

Three international organizations have negotiated reductions on key first- and second-line, and paediatric antiretrovirals (ARVs) that will help countries save at least US$600 million over the next three years.

The Clinton Health Access Initiative (CHAI), the international drug purchasing facility UNITAID and the UK Department for International Development (DFID) made the announcement on 18 May.

The deal expected to affect most of the 70 countries comprising CHAI’s Procurement Consortium, features notable reductions in the prices of tenofovir (TDF), efavirenz, and the second-line ritonavir-boosted atazanavir (ATV/r) used in HIV patients who have failed initial, or “first-line”, regimens.
Read the rest.

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

18 May 2011


In conversation with Linda-Gail Bekker, an award-winning scientist and self-described “frustrated social worker.”

It’s been quite the roller coaster in the PrEP world recently. On the downside, April saw the closure of the FEM-PrEP trial due to “futility” (read the Mapping Pathways blog posts on this here and here). On the upside, we received exciting news this month from the HPTN 052 study, which confirmed that treatment as prevention works (read the Mapping Pathways post here).

With all this news relating to various studies and trials, we thought to check in with Dr. Linda-Gail Bekker from the Desmond Tutu HIV Foundation (DTHF) in South Africa, a Mapping Pathways partner organization. Dr. Bekker is one of the foremost experts in the field of biomedical trials and research.

She, along with her colleagues, is currently finalizing preparations for a new PrEP trial slated to begin during the second half of this year. Unlike other similar trials underway (such as the VOICE trial), the ADAPT study will focus more on the behavioral aspects of intermittent PrEP in sites in Bangkok (men who have sex with men) and South Africa (women who have sex with men). Explains Dr. Bekker, “It’s a feasibility study, it’s not an efficacy study. It’s looking at dosing –  intermittent PrEP vs. event-driven PrEP (time of sex) vs. daily PrEP. The question is really about what’s your preference?”

Determining this “preference” includes exploring questions like: how easy or difficult are the different dosing regimens of PrEP to follow; if given the choice, what would be a person’s preference for the frequency of dosage; and how adherent are people to PrEP depending on this frequency?  Asks Dr. Bekker, “How do you get truthful information around sexual risk and practices, and how do you gain authentic information around adherence? There’s a huge amount of research to be done. We’ve tended to keep behavior at arm’s length … but how do you get to the heart of that?” 

To put it simply, regardless of whether PrEP is effective or not, people need to adhere to it for it to work; just as, although it’s been proven that condoms are effective, people need to use them in the first place. The ADAPT study is trying to determine whether the frequency of PrEP dosage influences this adherence or not.

This is an interesting concept because it looks beyond the science of PrEP to the behavior of PrEP, and the complexities and nuances of human behavior are wild cards Dr. Bekker often encounters in her work.

Dr. Bekker, the principal investigator for the iPrEx study’s Cape Town site, says the only certainty in this field is that anything is possible. For instance, until the FEM-PrEP endpoint results and analyses are released, it’s anybody’s guess as to whether the trial was deemed futile due to adherence issues or whether it was efficacy issues. Says Dr. Bekker, “Wait for the evidence, I think that is the message. Extrapolate at your peril. We know only what we know, and we need to just work within that. I think whenever the field starts to go on emotion, we get into trouble.”

 “Human behavior keeps messing up the plot,” she continues. “For example, if we could tell people to just use condoms 100% of the time or go with a ‘Here’s a pill, swallow it’ approach as we would with a mouse or an automot, it would all be much easier. But the fact is that behavior and biology crash in the middle, and it’s difficult then to tease out what the biology is doing because the behavior has quite an undefined, nebulous impact. So it makes the work so much harder.”

Dr. Bekker’s solution?

“We go at it with evidence  we try and get as truthful information as we can, we understand as much as we can, we know as much as we can … and then I think we’ll do much better.”

Linda-Gail Bekker is deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape Town. She also serves as the chief operating officer of the Desmond Tutu HIV Foundation, a Mapping Pathways partner organization. You can read more about Dr. Bekker’s views and her work at the following links:

The Lancet: Linda-Gail Bekker: confronting the TB/HIV co-infection epidemic

New Statesman: Linda-Gail Bekker Extended Interview Linda-Gail Bekker scoops award for TB/HIV

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

17 May 2011

HPTN 052 study finds 96% reduction in HIV transmission with early initiation of ARV treatment of infected partner

Press Release

An HIV Prevention Trials Network study (HPTN) found that men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners through initiation of oral antiretroviral therapy (ART).

The study was designed to evaluate whether immediate versus delayed use of ART by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners and potentially benefit the HIV-infected individual as well. Findings from the study were reviewed by an independent Data and Safety Monitoring Board (DSMB).

The DSMB recommended that the results be released as soon as possible and that the findings be shared with study participants and investigators. The DSMB concluded that initiation of ART by HIV-infected individuals substantially protected their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission.

HPTN 052 is the first randomized clinical trial to show that treating an HIV-infected individual with ART can reduce the risk of sexual transmission of HIV to an uninfected partner.

Read the full release.

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

14 May 2011

BIG NEWS: Transmission Risk Reduced By 96%, Study Results Show

via Kaiser Family Foundation

Results from a multicountry clinical trial, sponsored by the National Institute for Allergy and Infectious Diseases (NIAID), show that HIV-positive people who take combination antiretroviral therapy (ART) can reduce the risk of transmitting the virus to their HIV-negative partners by 96 percent, U.S. researchers announced on Thursday "[i]n what is being hailed as a breakthrough in HIV prevention," the Los Angeles Times reports (Maugh, 5/13).

Read the rest of this news summary here.

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

FEM-PrEP CLOSURE UPDATE: What does “futility” mean exactly?

It’s only been a few months into 2011, and last year’s trend of headline-making PrEP-related news continues. Last month, the FEM-PrEP trial was halted due to futility. This means that it was determined the study could not answer the question of whether daily Truvada worked, or not, in terms of preventing HIV among the trial population. Click here for the Mapping Pathways post on the trial closure.

Data collection for a final endpoint analyses report has begun. According to sources from Family Health International (FHI), primary endpoint data gathering will continue till around August 2011, and a final analysis of the primary endpoint and some secondary analyses can be expected to be completed by the end of this year. See more about the objectives and endpoints for these analyses here.

Meanwhile, as we await this report, many interesting conversations have been taking place about possible causes for the trial’s closure and what this might mean for the big picture on PrEP. How will this affect other similar trials, such as the VOICE trial, which is underway? What about future biomedical trials? What caused FEM-PrEP to be unable to answer the central question of the trial and be deemed “futile”⎯was it biological gender differences in drug activity and route of exposure, socio-cultural factors or simply flaws in the study design? How big a factor was adherence, and what lessons can we learn for future trials to create better ways of monitoring and encouraging adherence?

“There’s still so much we don’t know, and these are open questions rather than being settled questions,” remarked Julie Davids, Director of National Advocacy and Mobilization and lead coordinator of the HIV Prevention Justice Alliance from the AIDS Foundation of Chicago, a Mapping Pathways partner organisation. Davids, who observed that a “healthy conversation” was now happening among advocates, people living with HIV, researchers and others, also commented on the idea of “futility”: “‘Futility’ in common usage sounds really bad; outside the trial context, it means ‘hopeless.’ But in fact, in the trial context, ‘futility’ is not a definitive answer. It simply means that we don’t yet know and this way we’re proceeding is not going to answer the question⎯we can’t prove that the intervention worked, and we can’t prove that the intervention didn’t work … There are still things to be learned.”

John S. James from AIDS Treatment News looked at the trial’s closure from a behavioral point of view, discussing the need for science to take socio-cultural factors into account: “The iPrEx trial worked much better at the U.S. sites (Boston and San Francisco) than at other sites, where participants would often have strong reason to give their medication to someone who was sick due to HIV, and not tell the researchers. All of the FEM-PrEP sites were in Africa, where access to life-saving HIV treatment is much worse than in Boston or San Francisco. Unlike iPrEx, FEM-PrEP had no U.S., European, or other sites where no one would need to divert the pills to save the life of a family member or friend.”

Read on for a lively discussion on the how’s, why’s and what-if’s of FEM-PrEP

11 May 2011

Antiretroviral Drugs Dramatically Reduce Risk of Passing HIV to Healthy Partners

via Health Behavior News Service, by Glenda Fauntleroy

When one partner in a couple is infected with HIV and the other is not, treatment with antiretroviral drugs can dramatically lower the chances of the infected partner passing along the disease to his or her mate, a new evidence review finds.

Patients with HIV receive a combination of drugs is given as part of antiretroviral therapy (ART) to stop progression of the disease. The new review discovered that when patients with HIV are on ART, their partners had more than a five-fold lower risk of getting the virus than in couples without treatment.

“We weren’t particularly surprised having followed this literature for awhile,” said reviewer George Rutherford of Global Health Sciences at the University of California, San Francisco. “The magnitude of the effect was somewhat surprising, though.”

Read the rest.

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

10 May 2011

Factors Influencing the Emergence and Spread of HIV Drug Resistance Arising from Rollout of PrEP

Factors Influencing the Emergence and Spread of HIV Drug Resistance Arising from Rollout of Antiretroviral Pre-Exposure Prophylaxis (PrEP)



The potential for emergence and spread of HIV drug resistance from rollout of antiretroviral (ARV) pre-exposure prophylaxis (PrEP) is an important public health concern. We investigated determinants of HIV drug resistance prevalence after PrEP implementation through mathematical modeling.


A model incorporating heterogeneity in age, gender, sexual activity, HIV infection status, stage of disease, PrEP coverage/discontinuation, and HIV drug susceptibility, was designed to simulate the impact of PrEP on HIV prevention and drug resistance in a sub-Saharan epidemic.

Principal Findings

Analyses suggest that the prevalence of HIV drug resistance is influenced most by the extent and duration of inadvertent PrEP use in individuals already infected with HIV. Other key factors affecting drug resistance prevalence include the persistence time of transmitted resistance and the duration of inadvertent PrEP use in individuals who become infected on PrEP. From uncertainty analysis, the median overall prevalence of drug resistance at 10 years was predicted to be 9.2% (interquartile range 6.9%–12.2%). An optimistic scenario of 75% PrEP efficacy, 60% coverage of the susceptible population, and 5% inadvertent PrEP use predicts a rise in HIV drug resistance prevalence to only 2.5% after 10 years. By contrast, in a pessimistic scenario of 25% PrEP efficacy, 15% population coverage, and 25% inadvertent PrEP use, resistance prevalence increased to over 40%.


Inadvertent PrEP use in previously-infected individuals is the major determinant of HIV drug resistance prevalence arising from PrEP. Both the rate and duration of inadvertent PrEP use are key factors. PrEP rollout programs should include routine monitoring of HIV infection status to limit the spread of drug resistance.

Read the full text on PLoS One.

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

09 May 2011

Presentations from 2011 MTN Annual Meeting Now Available

The 2011 Annual Meeting of the Microbicide Trials Network was held in Washington, DC this past March.

Very informative plenary presentations occurred on the two main days of the meeting. The MTN and all the presenters have graciously provided access to their slide sets. Below are links to each of them - just click on those you find interesting. Please take advantage of this great set of resources.

Presentations from Plenary Sessions on Monday, March 28, 2011

Presentations from Plenary Sessions on Tuesday, March 29, 2011

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

07 May 2011

Real Lives, Real Change

In all of our discussions about statistics, studies, and scientific trials, we sometimes lose touch with the very real ways in which ARV-based medication can change people’s lives. Last week on the LifeLube blog, Nick Literski talked about his personal experience with PrEP, and how it has transformed his life and his relationship for the better.


Recently, I was surprised to learn that I had allegedly “given up on gay men.”

According to Michael Weinstein, president and founder of the so-called “AIDS Healthcare Foundation,” I now consider the lives of gay men, including myself, “disposable.” What great crime have I committed to deserve Mr. Weinstein’s condemnation? I take Truvada once a day, as pre-exposure prophylaxis (PrEP), in order to protect myself from HIV infection.

Read the rest of Nick’s thought-provoking account here.

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

06 May 2011

Tutu: South Africa No Longer Embarrassed Over HIV/AIDS Policies

via Associated Press, by Thandisizwe Mgudlwa

Cape Town's former Anglican Archbishop Desmond Tutu said Tuesday that South Africa has changed its AIDS policy and no longer should be ashamed of its policies to combat the epidemic.

"For many years we were embarrassed in international gatherings for what we were not doing in fighting AIDS. We therefore thank the Minister of Health Aaron Motsoaledi for the change in policy," said Tutu, who is officially retired but still working to bring peace and progress to the world.

In 2009, President Jacob Zuma pledged an ambitious testing and treatment campaign and more vigorous anti-AIDS efforts. Motsoaledi leads the campaign, and has been praised by AIDS activists who had repeatedly clashed with a previous health minister who promoted beets and garlic as AIDS treatment and questioned the link between HIV and AIDS.

"We are definitely joining hands with the rest of the world in the fight against HIV/AIDS. I think we will win," said Motsoaledi, who joined Tutu at a U.N. conference devoted to getting a new generation of activists involved in spreading the message about preventing AIDS.

Read the rest.

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

Initiating Anti-HIV Therapy at High CD4 Count Increases AIDS-Free Survival

via and CDC

Starting combination antiretroviral therapy (ART) at the threshold of 500 CD4 cells/microliter, rather than at 350 or lower, significantly reduces HIV patients' risk of progressing to AIDS, a new study shows.

US recommendations indicate treatment at the 500-cell point for asymptomatic HIV patients, while European and World Health Organization guidelines call for treatment at the 350-cell level. The authors of the current study -- Dr. Lauren E. Cain, with the Harvard School of Public Health, and colleagues -- said information from randomized trials is inadequate to decide between the two approaches, and two large observational studies have yielded conflicting results.

Read the rest.

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

03 May 2011

HIV PrEP Explained: Critical Prevention Opportunity

 via AIDS Treatment News, by John S. James

This is an excellent summary of the iPrEx trial that showed Truvada could protect against HIV in gay men. Additionally, it analyzes the implications of the study in a very clear, thoughtful manner.

Since doctors can legally prescribe Truvada for prevention now, the U.S. CDC (Centers for Disease Control and Prevention) in January 2011 published interim guidance for physicians who want to use it to prevent HIV infection in high-risk HIV-negative men who have sex with men.[6,7]. Guidance will change as more information becomes available from other studies currently ongoing.

The main obstacle now is the price. Gilead Sciences, which holds the patent on Truvada, charges about 100 times as much for Truvada in the U.S., as other companies charge profitably for the same generic medicine in countries where Gilead's patent does not apply. And unless the FDA approves a formal "indication" for prevention use, insurance is unlikely to pay. This means that you can get Truvada for prevention in the U.S. today -- if you have over $12,900 per year to spend out of pocket -- or possibly, very good health insurance. (Gilead raised the price early in April, 2011; on April 18 we checked retail prices on, which offers 90 once-daily pills for $3,180,90.)

Clearly PrEP will not be used enough to impact the epidemic, if individuals must pay so much out of pocket. (Just taking a $35 pill before sex is not expected to work. The body must convert both drugs into their active forms, which takes time.
Read the rest.

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

Mapping Pathways Partner Profiled in Washington Post

Mapping Pathways partner Mark Ishaug was recently profiled in the Washington Post. Mark is the new president and chief executive of AIDS United, a District-based national policy and grantmaking organization that seeks to end AIDS in America. Previously he led AIDS Foundation of Chicago (another Mapping Pathways partner, in addition to NAZ India, Desmond Tutu HIV Foundation, RAND Europe, and Baird's CMC.)

via Washington Post, interview by Vanessa Small

After witnessing the devastating effects of AIDS on friends and people he knew, Ishaug knew he wanted to contribute to ending the disease — he just wasn’t sure how. It wasn’t until the owner of a restaurant he worked in made a call to the AIDS Foundation of Chicago on his behalf that Ishaug found his place in the movement. He rose through the ranks to lead the organization and after 20 years decided to take on a leadership role in the District that he believes will “benefit a bigger and broader arena.”

Read the rest.

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

02 May 2011

Using Antiretrovirals to Prevent New Infections

Mark Chataway is co-chairman of Baird’s CMC, a Mapping Pathways partner organisation. Here, he outlines the various prevention strategies.

I have been involved in fighting AIDS since 1983. I was the first full-time communications director of an AIDS organisation in the US. At the time, none of us imagined how terrible the epidemic would get – I remember a time when most of my colleagues thought that only people who had had over 100 sexual partners a year were at risk.

Like most people who’ve been so close to the epidemic, I often lose sight of how much progress we have made. The epidemic peaked long ago and the number of cases is falling every year. That is the kind of public health success that has not often been seen in the modern era. We are most of the way towards eliminating AIDS in the industrialised world although shocking epidemics still exist in many developing countries. There are still a tragically large number of caofses in Southern and Eastern Africa and the threat of HIV breaking out at-risk communities persists in parts of Asia and maybe even Eastern Europe.

There is a threat – still distant but definitely visible – that we will lose this astonishing success through complacency. Very few of us realised how fast we could cripple the epidemic once we started treatment. A few of us risk forgetting how fast the epidemic will bounce back if we allow treatment rates to slip.

We can make AIDS rare – and eliminate it entirely from rich countries – using technologies that we already have. The question is whether we have the will to do it.

There are three promising strategies for using the medicines we have as prevention.
  1. Treat enough HIV-positive people with antiretroviral medication, in an effective manner: If we improved access to treatment for people living with HIV, including the offer of treatment earlier in the course of the disease, there is evidence that the “community viral load” would fall. Providing effective treatment to more individuals with HIV can reduce onward infections in a community because people on treatment are less likely to transmit the virus. The chances of HIV-negative people becoming infected would reduce progressively over time. An approach that focuses on improving access to care and antiretrovirals is sometimes called TLC+ (testing, linkage to care, plus treatment).
  2. Provide antiretroviral medication for HIV-negative people who are at high risk of infection: Some HIV-negative people at the highest risk of being infected by HIV cannot modify their risk of being exposed. For example, sex workers may be unable to persuade their clients to use condoms and intravenous drug users may not have access to clean needles. For many of them, stopping the underlying risk behaviour – sex work or drug use in these examples – is not feasible. These HIV-negative people, at very high risk of infection, can be offered antiretroviral medicines to lower their chances of becoming infected in the future. They would have to take these medicines routinely and they would still be at some, albeit lower, risk of becoming infected if they could not avoid risky behavior. This approach is usually called pre-exposure prohphylaxis (PrEP). Recent trials have shown that PrEP can reduce the risk of infection significantly in gay men although puzzling findings suggest that they may not protect women.
  3. Provide topical, antiretroviral-based microbicides to HIV-negative people: Antiretrovirals could be used topically – in a gel or lubricant formulation, for example – in the vagina or the rectum by HIV-negative people. The topical medicine could reduce the risk of HIV acquisition. This approach is often called microbicides or topical PrEP. A recent study in South Africa proved that the concept works and showed a degree of efficacy in protecting women from infection. Other studies have provided encouraging data on rectal and vaginal products.
Some behaviour change efforts have worked well – especially those run by affected communities for their own vulnerable people. Many behaviour change efforts barely worked at all but continue to be funded because there have been no alternatives. (Evaluation of individual efforts will always be complex – see, for example, the extended debate over the evaluation of the LoveLife programme in South Africa – but Northern Europe is an interesting example: countries such as Belgium, the Netherlands and the UK followed very different behavioural interventions but all have ended up with very similar epidemics.) Money from under-performing programmes can be re-directed to prevention efforts that have been proven to be effective in well-controlled prospective trials. Effective prevention, of course, reduces the need for treatment in the medium to long term.

My colleague, Jim Pickett, uses car safety as an analogy: nothing can take the place of safe, skilled driving but seat belts, air bags and better car design have reduced the number and severity of accidents dramatically, even as the number of cars and drivers has increased. These three approaches to using antiretrovirals might be the air bags, seat belts and safety frames of the HIV epidemic.

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