Saturday, July 16, 2011

Presentation at Kilimanjaro Clinical Research Institute

Hordes of articles are appearing right now about some promising results from the use of antiretroviral drugs (ARV) to prevent HIV, as opposed to treating it. This is called pre-exposure prophylaxis or PrEP. But the question is, who will benefit from this use of ARVs, which has mainly been tested on Africans?

ARVs are expensive, despite all the posturing about agreements and deals brokered by Bill Clinton and other notable self-publicists. They are so expensive that few countries with serious HIV epidemics and large scale treatment programs have ever been able to cover more than half of the HIV positive population, at most. Usually coverage is a lot less than half.

The biggest programs in East Africa only include a few hundred thousand people, out of millions infected. But HIV negative populations are many times larger than HIV positive populations. Over 90% of the populations in all the East African countries are HIV negative. How will people be selected for PrEP programs? According to the HIV industry most sexually active Africans are at risk of being infected.

Yesterday I had the pleasure of making a brief presentation about sexual and non-sexual HIV transmission to a group of people who work or study at the Kilimanjaro Clinical Research Institute, part of the Kilimanjaro Christian Medical Center (a powerpoint of the presentation slides is available on the KCRI site). The talk was about my usual concern, the 'behavioral paradigm'. This is the view that HIV is almost always transmitted through heterosexual sex in high prevalence African countries.

This 'paradigm' is not based on evidence. In fact, it is frequently contradicted, especially by UNAIDS's own data. But as the flagship of the AIDS industry, this means that resulting UN policy is almost entirely based on what amounts to an extremely racist view. How will that racism, which so far has resulted in a lot of money being spent on large-scale finger-wagging exercises, affect the rollout of PrEP?

One of the slides I used at the presentation was a screenshot of the mathematical model used to back up the industry's claim that most Africans are at risk of being infected with this difficult to transmit virus. The 'Modes of Transmission Survey' for Kenya, for example, suggests that 44% of the 1.5 million HIV positive people were infected by ordinary heterosexual sex. And members of other groups that would be considered to be at low risk in non-African countries are also mysteriously infected in huge numbers.

UNAIDS' argument for this is somewhat circular because the claim that members of the largest group of HIV positive people are infected by their regular partner is supported by the idea that most regular partners have, or at one time had, 'unsafe sex'. But these are just more assumptions based on the behavioral paradigm, not pieces of data that might support it.

It's hard to know whether this adherence to the behavioral paradigm is going to blow up in the industry's face, or whether it will just feed their ongoing demand for profits at any cost. If virtually every sexually active person in a population is at risk, will they all be offered PrEP? Or are UNAIDS going to claim that PrEP is not appropriate for groups that have been considered to be at high risk up to now?

There is also a problem right now about funding ARVs for people who would die without them. Who will stump up tens of times more funding for drugs for people who will not die without them, probably won't benefit from them at all and may even be harmed by them? If saving the lives of some HIV positive people is not considered worth the effort, is it worth the cost and effort to play around with the lives of huge numbers of people just so pharmaceutical companies can become even richer than they already are.

My worry is not just about the use of drugs to reduce HIV transmission. My worry is about the serious lack of clarity about why certain people, mostly Africans, are so susceptible to a virus that is difficult to transmit sexually, yet so many are infected. Simply throwing a lot of drugs at the problem is unlikely to make it go away. This problem needs to be explained without the use of the thoroughly discredited behavioral paradigm.

[For more about pre-exposure prophylaxis, see my other blog.]


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