Saturday, August 11, 2012

Dancing Bears Demonstrate Effectiveness of 'Evidence on Demand' Policy

Naturally, after spending tens of millions on the recent International Aids Conference in Washington DC, the HIV industry is buoyed up and ebullient. "The goal of an AIDS-free now within sight", according to the Secretary of the US Health and Human Services. Equally naturally, that means the industry needs more money. Conferences like that don't pay for themselves.

Meanwhile, an article on antiretroviral drug resistance in Africa, which is increasing quickly, attributes this increase in part to "limited national infrastructure, a shortage of healthcare professionals, inconsistent supply chains, and weak enforcement of quality standards", which makes a change from blaming the people taking the drugs. It would be interesting if the research resulted in a change to HIV related spending, which tends to concentrate on commodities and ignore things like infrastructure, personnel, health systems and quality.

In fact, even though it refers to the US, another article mentions some 'new iniatives' which include addressing infrastructure, health systems, education and patient support that, presumably, goes beyond the mere distribution of ever increasing quantities of drugs. Not only are all the worst HIV epidemics to be found in some African countries, but some of the worst healthcare facility conditions are also to be found there, not to mention poor infrastructure, low educational standards, poverty and abysmal living conditions.

The much trumpeted 'game-changer', treatment as prevention, will certainly require a lot more than provision of drugs. In a country with very high levels of health spending, such as the US, providing drugs and various other aspects of treatment has had mixed results. According to a 'treatment cascade', of the over 1 million people infected with HIV, 80% know they are infected, 62% are linked to HIV care, 41% have stayed in HIV care, 36% are receiving treatment and 28% have a very low amount of virus in their bodies.

I haven't seen a similar 'cascade' for any high prevalence country. But the percentage who know their status tends to be a lot lower. As for figures at other levels of the cascade, they are probably unknown and certainly questionable. If the aim of treatment as prevention is to ensure that as many people as possible, perhaps as many as 80% of HIV positive people, have a low viral load, it will not be the mere distribution of drugs that will count the most. These countries will also need to address health more broadly than they have done for decades, also education, infrastructure and other areas of development.

A study in Uganda has found that antiretroviral treatment has not reduced new infections in couples. There was no difference in transmission rates between those couples on treatment and those not on treatment. Someone involved in the study has said "It may be difficult to extrapolate the results of randomised controlled trials to real-life situations in low-income countries". Quite. Another study in Uganda found that population viral load did decrease in a 'test and treat' scenario, but it is not clear if this resulted in reductions in transmission rates.

But the first Uganda results seem to carry the customary HIV industry assumption that almost all HIV transmission is sexual. Phylogenetic testing showed that in two cases the virus probably came from the already infected partner and in one case it did not. It is concluded that the one that did not came from an extramarital partner. Did they check? All three could have been infected through some non-sexual route. What steps did the researchers take in order that they could be so sure that all three infections were heterosexual?

A commentator says "Our results do not question ART working as a prevention tool",..."only that the effect can be undermined by social, biological and cultural factors that can underlie transmission", which seems to be an admission that transmission is not entirely down to sexual behavior. But this still doesn't rule out the possibility that some transmission was not sexual at all, that it was a result of unsafe healthcare or other skin-piercing practices.

It seems unlikely that the industry would be spending so much on big parties (or conferences, or whatever) if the show is almost over, or even if the end is 'in sight'. But while the money is still flowing it would be good to think that some of the poorest areas in the world would benefit from a bit of so-called aid spending. Otherwise, once the world is finally 'free' of AIDS, most of those suffering from HIV and its effects will not be among those celebrating.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


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