Friday, April 27, 2012

HIV Prevention: Blinded by Profit or Paid Not to See?

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.]



Petit Poulet said...

I think I have to disagree with you on ARTs. While someone will make money off the sale of these agents, they may be the most cost-effective prevention currently available. Secondary prevention, especially in areas where the prevalence is low, but also in Africa with the prevalence is higher, is a much better option than primary prevention. One could argue that the low rate of sexual transmission makes condoms unlikely to be effective and circumcision even less likely to be effective. ARTs make sense for infected mothers as this would prevent 20% of infections in Africa. If ARTs result in a reduction in blood-borne transmission this may also be a good approach.

I think the problem is that too many people are looking for simple intervention that will take care of the problem. ARTs are a big part of the solution as far as prevention goes. Getting clean needles and medical equipment is a good idea by itself and may go further than ARTs in prevention HIV infections. I think it is wrong to pooh-pooh ARTs when they show much more promise than other alternatives.

Part of the mindset that needs to be overcome is that in the situation where there is no evidence, earlier treatment is presumed to be better than late treatment and more is more. As much as I think it is wrong to dismiss ART, it is equally wrong to believe that it provides the ultimate solution.

Simon said...

Hi and thank you for your comment. However I urge you to read the post again if you think I am opposed to the use of ART, because it makes gratuitously large profits for drug companies at the expense of poor and vulnerable people or for any other reason. I am opposed to the use of questionable arguments for the creation of policies that affect people's lives so profoundly when empirical data is lacking or patently contradict the policy directives.

Regarding mother to child transmission, again, I am in no way opposed to the use of ART where this would improve the health of the mother and/or that of the child. But presenting drugs as a solution to HIV transmission very often draws attention away from the risks those infected face. If the risks are avoidable, treatment is not the best option, prevention is. The best way of preventing mother to child transmission is to prevent transmission to mothers, but this is often seen as somewhat irrelevant.

Drugs, and a lot more besides, are for sick people, not for healthy people. They are probably ineffective, almost definitely inefficient, for HIV prevention among adults and for those who are or who are said to be at risk of sexual transmission. And the idea of throwing drugs at people when it is the health services they depend on that are spreading the disease is totally ridiculous.

As for your remark about situations where there is no evidence, in the case of early treatment and various other circumstances where efforts are being made to increase ART use at all costs, there is no evidence for these strategies and there is a good deal against.

I'm not dismissing ART, just the misuse of drugs, which are not health; and health is not the absence of disease. Health policy is being directed by big pharma, and this is as stupid as security policy being directed by those who make outrageously inflated profits from violence and war (which may or may not happen).