Sunday, January 17, 2010

Fiddling with Technical Fixes While People Continue to Die

Time reports on a study which raises concerns about HIV drug resistance. Most Kenya government documentation about HIV treatment is concerned with getting as many people on treatment as possible, or appearing to do so. Where the aim is to get as many drugs out to as many people as possible, resistance is probably not so visible. After all, you need to monitor people regularly and carefully for signs of resistance and funding doesn't always stretch to that.

It's not really clear how many people in Kenya are currently on HIV treatment. Figures vary a lot and don't always make it clear whether people who were once on treatment but have since died are included. Probably a few hundred thousand are on treatment at the moment, maybe three hundred thousand. But it's even less clear how many are on second line treatment. Second line treatment is given to those who have developed resistance to first line treatment and it's prohibitively expensive.

Most of the hundreds of millions of dollars of HIV money is spent on drugs, either for treatment or prevention. No one would want to deny people who are suffering from HIV/Aids access to necessary drugs, of course, but there must be a limit to how much money can be spent on drugs to the almost total exclusion of other aspects of treatment and prevention. I don't know what that limit is but there are proposals to put even more people on drugs and the sustainability of these proposals is highly questionable.

At present, people whose HIV infection has reached a particular stage are usually put on antiretroviral drugs (ARV). Perhaps about half the HIV positive Kenyans who have reached this stage are currently receiving treatment. Pregnant women who are infected with HIV are put on a short course of ARVs and this results in most babies growing up HIV negative. Less frequently, people who may have been accidentally infected with HIV can be given a short course of ARV treatment called post exposure prophylaxis (PEP).

But there are proposals to roll out ARV drugs to more and more people. For example, it was proposed just over a year ago to test everyone, or as many people as possible, and to put anyone found to be HIV positive on ARVs. If this could be done, the number of people on treatment would go up several hundred percent.

Another proposal is to roll out what is called pre-exposure prophylaxis (PrEP). This would involve putting HIV negative people on ARVs in the hope that this would protect them from becoming infected. The target of this kind of programme would be those seen to be most at risk of contracting HIV. This could involve sex workers, men who have sex with men, prisoners, intravenous drug users and perhaps the clients of sex workers, people who have many parters and people who have concurrent sexual partners, relationships that overlap with other relationships.

The number of people who would be targeted would be hard to estimate. How many men who have sex with men are there in Kenya? Is it five percent of the population or 10 percent (2-4 million)? Men who have sex with men are hardly going to identify themselves in the current homophobic climate anyway. An obvious target of PrEP is people who are HIV negative but are in a relationship of some kind with someone who is HIV positive, called discordant relationships. This could number some 350000 people.

Similarly for sex workers, how many are there? Is it hundreds of thousands and does that include people who occasionally engage in sex work or who don't consider themselves to be sex workers? And what about identifying their clients, how many million would there be? Is it really feasible to identify those most at risk of becoming infected with HIV? The recently published modes of transmission survey shows that, for years, HIV programming has been seriously misdirected and also that those who are most at risk is a very mixed and constantly changing group.

There are questions about the possible effectiveness of PrEP but there must also be questions about the feasibility of identifying all the people who could benefit from it, given the numbers of people who are infected with HIV and the numbers of people who are in danger of becoming infected. If resistance is a problem at current levels of ARV rollout, what kind of problem would it be if ARVs were rolled out to all people at risk or thought to be at risk of contracting or of transmitting HIV?

All the uses of ARV run the risk of resistance. Those who are HIV positive and on ARVs are at risk, but so are the women who receive short courses of ARVs to prevent mother to child transmission, so are those who receive post exposure prophylaxis, so are those who receive pre exposure prophylaxis. With resistance comes increased sickness and death unless second line treatment is rolled out. And second line treatment means increases in cost of several hundred percent. Again, questions about sustainability arise.

The question of whether we can treat our way out of the HIV epidemic is constantly raised but the answer is unclear. I would suggest that the answer is no and that even efforts at preventing the spread of HIV should steer clear as much as possible from technical fixes, such as ARV drugs. Drug treatment of HIV, let alone drug prevention, may not be sustainable and is already seriously affecting the amount of money available for preventing HIV transmission.

Instead of the almost inconceivable amounts of money being proposed to pay for drugs for treatment and prevention, far lower sums of money could be spent on improving the overall health, education and welfare of Kenyans and of those in other high HIV prevalence countries. It is immoral to continue pretending that there is a technical fix just around the corner and that everything will be OK. As long as we continue to look for technical fixes and ignore the lives of people in underdeveloped countries, people will continue to become sick and to die from treatable and/or preventable conditions.

(For further discussion of PrEP, see my other blog,



Simon said...

There's further information about the effect of resistance on a 'Test and Treat' policy here:

Simon said...

And here's another article about resistance: