Friday, April 27, 2012
We have been hearing a lot recently about various HIV treatment and prevention strategies that will significantly increase the quantities of HIV drugs produced and sold. For example, the US DHHS recommends starting antiretroviral therapy (ART) for HIV positive people at a relatively early stage of disease progression. One might think that such decisions are made on the basis of scientific evidence and concensus among medical practitioners. But Joseph Sonnabend shows that this is not necessarily so.
Dr Sonnabend finds that 'expert opinion' in this instance refers to that of DHHS panel members, most of whom have a financial interest in selling more drugs. There are many experts who would not agree that starting ART early has a net benefit, but they don't sit on the panel. There is scientific evidence for the benefits of starting later, but none for those of starting earlier. Basing such decisions on the expert opinion of a few people is bad enough; expert opinion should never trump scientific evidence. But when most of the experts can also benefit financially from the recommendation as well, there is a clear conflict of interest.
ART must be taken for life and has side-effects, only some of which are currently recognized. It is also expensive and life changing. And there is the issue of the virus developing resistance to the cheaper drugs that people usually take at first. Resistant strains of HIV can be transmitted, so there could be a snowball effect here. We already know what can happen when drugs are overprescribed and adherence is poor from the case of antibiotics and perhaps malaria medication. So this is not a minor issue about precription recommendations. In contexts where HIV is common, it could profoundly affect the course of the epidemic.
It's fashionable enough these days to claim that 'treatment is prevention', but as Dr Sonnabend points out, it is those who have reached a later stage of disease progression who are most likely to transmit HIV. Therefore, the preventive value of ART will only be high for partners of people who start treatment at a later stage. Treatment at an earlier stage will be less relevant, perhaps irrelevant, and the benefits have not been shown to outweigh the risks. While it may be empowering to provide people with the drugs they demand, it is only so if they are also informed about the known effects of those drugs, in addition to the hypothesized ones.
WHO has also made a recommendation that similarly serves the interests of Big Pharma. As the English Guardian reports, "Aids drugs should be given immediately to anyone with HIV who has an uninfected partner, to stop transmission and slow the epidemic". As mentioned above, this is unlikely to slow the epidemic much and could have many drawbacks which have, as yet, not been investigated. Resistance rates are steady enough to guarantee that people taking relatively cheap (but still grossly overpriced) first line drugs will gradually need outrageously overpriced second line, and even third line drugs. And resistance will eventually develop in second and third line drugs too, as they have found in Uganda. Quite a virtuous cycle for Big Pharma!
Far from just being used to treat HIV positive people and to prevent transmission to HIV negative people, ART programs appear to have the effect of drawing attention away from possible HIV risks. How has a virus that is difficult to transmit heterosexually infected, for example, 43% of adult women in Mozambique and nearly 38% of adult men? There are clearly non-sexual risk factors involved, but what are they? If diseases such as malaria, TB, intestinal parasites and the like are involved, for example, they urgently need to be treated and prevented, which can be done cheaply and relatively safely. But if the virus is being transmitted through unsafe healthcare practices, showering people with drugs is a misdirected effort and may not even reduce transmission.
The relative contributions of all risks need to be identified, whether they relate to sexual or non-sexual transmission. But putting more and more people on drugs while ignoring possible risks is not the way to eradicate the virus. Two things that are blind to the causes of HIV transmission and to appropriate prevention strategies are drugs and high profits. Of course, Big Pharma make drugs and big industries, especially the HIV industry, make profits. But the problem is when profit is seen as the only goal and treatment is seen as a mere step to be taken in the pursuit of profit. As for prevention, the industry seems to be looking for ways of making money out of it rather than for how best to achieve it.
[For more about non-sexual HIV transmission and male circumcision, see the Don't Get Stuck With HIV site.]