Could PrEP be in Competition with Mass Male Circumcision Programs?

[Reposted from the Pre-Exposure Prophylaxis (PrEP) Blog]

After years of trying to create a market for pre-exposure prophylaxis (PrEP) pills, such as Truvada, Big Pharma has turned to their favorite mass marketing ploy: dumping their products in African countries that are starved of health funding. Of course, why wouldn't they dump them in Africa, won't they be paid for with donor funding?

An article in Kenya's The Star entitled "Kenya: 'Wonder Pill' for Risky Sex On the Way" takes the unusual step of raising some difficult questions about PrEP, rather than repeating the Big Pharma press release, despite a shaky introduction. The article continues "Kenyans involved in risky sex behaviours will soon get a 'wonder pill' that can prevent HIV infections. Experts say Truvada, which some call the 'new condom', can reduce chances of catching HIV but there are fears the drug may be misused by the youth".

What, exactly, would constitute misuse of the drug? If it can cut the risk of infection by "up to 75 per cent if one faithfully swallows it daily", what could go wrong? Well, as the article eventually reveals, most people don't swallow drugs daily and most people can not expect 'up to 75%' reduction in risk. That figure is not even from a randomized controlled trial, but from a 'sub-group' study, where the best results are used to exaggerate the level of protection people, in (comparatively) strict trial conditions, may expect. Outside of that sub-group, and outside of drug trial conditions, risk reduction is far lower.

It's odd that such reports talk about studies and proofs for something that they then refer to as a 'wonder pill', a 'new condom' and talk of 'up to 75% protection' (although that's a bit weak compared to the term 'invisible condom' used by those marketing mass male circumcision), and the like. These are PR buzzwords, not scientific findings.

It is said that PrEP programs intend identifying those most at risk of being infected, such as sex workers, intravenous drug users and men who have sex with men. This will be a departure from vilifying these already stigmatized and criminalized groups; it remains to be seen how much donor funding will actually be spent on these groups to provide them with PrEP, given that it has been so difficult in the past to provide them with condoms, injecting equipment and even basic sex and sexuality education.

As the article says, Truvada is expensive, and it has made billions of dollars for Gilead. So it's worth their while pushing as much of the stuff as possible in countries with high HIV prevalence while the patent guarantees that their product will face little competition. By the time the patent expires the likes of Bills Clinton and Gates will surely have set up some program whereby the drugs can continue to be purchased at inflated prices.

The article makes the important point that nearly 1 million HIV positive Kenyans currently need antiroviral drugs just to keep them alive. So why would donors want to provide these same drugs to people who are not yet infected with HIV (aside from an obvious desire to enrich big pharma)?

Oddly enough, a cost effectiveness study makes its estimates using existing levels of male circumcision and antiretroviral therapy. This means that the three multi-billion dollar programs will be in direct competition with each other for funding, and each one will be trying to claim that any drop in HIV incidence is a result of their work. The study also seems to assume far higher levels of success than have been achieved so far. But that's big pharma for you.

While Gilead and other pharmaceuticals can gain a lot from any increase in antiretroviral therapy and PrEP programs, they may not stand to gain from mass male circumcision programs. Their assumption that their PrEP programs will be cost effective only in countries where circumcision levels are low suggests that by the time their product may be approved, the circumcision programs will already need to have failed, some time around 2015.

Worries that people may use PrEP as a kind of recreational drug, so they can dispense with the use of condoms when they are engaging in sex with people who may face a high risk of being HIV positive are not very convincingly addressed; nor are worries that overuse and misuse of antiretrovirals, either for HIV positive people or as PrEP, are brushed aside, with remarks about "government policy" and making the drug available "in form of a package that probably includes HIV testing and other prevention methods".

I seem to remember condoms, circumcision, ABC and various other programs being made available in the form of a package, without that leading to extraordinary results. But it will be interesting to see if PrEP will erode some of the funding currently being made available to, or earmarked for, mass male circumcision programs.

Circumcision programs stand to rake in billions for the big providers, but widespread use of PrEP would be worth far more. It's unlikely that a full scale version of both programs could co-exist; they are not mutually exclusive, but their cost effectiveness is predicated on their being the only or the main program in high HIV prevalence countries.

Whether one program displaces another, or whether they all get funded, the losers will be people in high HIV prevalence African countries, which will continue to suffer from under-funded health and education sectors. They will continue to be a mere 'territory' for sales reps, who will continue to carve things up in ways that should be very familiar to us by now.

Do Wealth and Power Exclude Wisdom?

To quote the late comedian Linda Smith, "I don't mean to sound racist, but rich people are weird." The very good climate change blog, climateprogress.org has an article about Bill Gates and his maunderings on climate change and related issues. The guy seems to know very little about climate change and all his information seems to come from corporate funded mouthpieces like Bjorn Lomborg.

Gates seems to think most of the current worries about climate change are pointless and that none of the proposals made by activists and experts should be considered. But he thinks that there will be a technological solution or two to the problems of clean energy, energy efficiency, etc (one of those solutions being nuclear, which he thinks is 'as good as' renewable).

This would sound very familiar to Gates-watchers. He advocates technical solutions to health problems, diseases such as HIV, TB, malaria, cholera and rotavirus. He also advocates technical solutions to problems like food shortages, food insecurity and low levels of food production (in the form of biotechnology). And for climate change, he advocates bioengineering. He's certainly consistent, so far.

Despite all his money and his rich and influential friends, Gates seems to be very misinformed and is falling behind on his knowledge of current research, but read the climateprogress.org article for the full details. He's into 'altering the stratosphere to reflect solar energy', filtering 'carbon dioxide directly from the atmosphere' and 'brightening ocean clouds'. Do we really want this lunatic to be let loose on the only life supporting planet we know of?

There's also a very strange article on allafrica.com purporting to be about poverty eradication that is really about a deal between the richest man in the world (Gates) and one of the richest and most rapacious corporations in the world (Coca-cola). The Gates Foundation is providing most of the capital, over 10 million dollars, to allow 50,000 Kenyan and Ugandan farmers to sell fruit to Coca-cola for 'fruit-juice' production.

The article is very short on detail and I don't see why Coca-cola can't get these farmers to sell fruit to them without the help of Gates. But is it really a good thing that these farmers are going to sell their healthy food products for what will be a very low price to an organisation that will convert them into an unhealthy and very expensive beverage?

Coca-cola is better known for covering otherwise beautiful areas with their revolting logos and other excrescences, for marketing harmful products to people who are starving and in need of fresh water, for polluting water supplies and using up water supplies in areas where water is scarce and for maintaining a very poor record of corporate social responsibility (see corpwatch.org for further details).

Rich people and organisations are weird, but they can also be sinister, completely undemocratic and downright inhumane. I'm not calling for a law against being rich or even curbs on how rich people can be. But I think rich people and organisations should be subject to the same laws as other people and organisations. And poor people should be protected from the excesses of the rich and powerful. Why should a handful of very rich people and organisations be able to dictate the future of the planet and the futures of all its inhabitants?

Widespread Environmental Contamination and Loss of Biodiversity Are 'Externalities' to the GM Industry

The Kenyan government has been persuaded that it can 'revive' the country's cotton industry by introducing genetically modified GM cotton varieties. The first thing that springs to mind is the principle reason for the death of cotton industries in Kenya and every other developing country in the world: subsidies for American cotton farmers. It is not possible for poor countries to produce cotton at a price that can compete with the heavily subsidized American cotton, which is why most country's cotton industries failed many years ago.

Of course, these American subsidies are illegal and they are completely antithetical to the country's constant bleating about the importance of free trade. But double standards have never mattered to rich countries and they never will.

There may well be theoretical benefits to GM organisms, such as cotton, it's hard to know. The GM industry has been pumping out inaccurate and misleading data on trials for so long that they probably don't even know what is true and what isn't by now, and probably don't care much, either.

But the problems that will arise if farmers buy into the thirty pieces of GM silver are more obvious, for those who can be bothered about them. The GM producer in question, Monsanto, which has an unrivalled corporate social responsibility record, claims that farmers will save on pesticide costs because they have to spray less frequently. Unfortunately, they will be obliged to pay more for seeds, spray using expensive pesticides produced by Monsanto and the land they spray will be denuded of all species, from the microscopic up. Expensive Monsanto herbicides will do the same for any plant species.

This is a mere externality to Monsanto and probably to the Kenyan government. The fact that the land and water surrounding land planted with this cotton will be contaminated, probably irreversibly, is also an externality and those promoting the introduction of GM cotton even have the cheek (or ignorance) to claim that it will have a positive impact on the environment and the health of those working on cotton plantations.

In addition to the problem of having to buy seed every year from Monsanto, because it's not possible or even permissible to collect seed at the end of the season, it will be difficult for the farmers to get out of the grip of Monsanto, if and when they wish to. Their land and the land around will be contaminated with the GM cotton for generations and even these contaminated crops could be deemed to the be intellectual property of those generous people at Monsanto.

Many of the claims put about by GM hawkers are yet to be backed up by evidence but even they make little effort now to deny that GM crops are unlikely to be of any benefit to small farmers. The vast majority of farmers in Kenya and other developing countries are subsistence farmers who aim to grow enough food to live on and sometimes grow some cash crops to supplement their income. Although various cash crops have long been foisted on small farmers, many have felt the sting of becoming locked into producing things like tea, sisal, coffee, sugar and biofuels, for example, only to find that yields and prices never match up to what they were promised.

Small farmers who buy into GM crops need to ask themselves if they can afford to become locked into yet another non-food crop that will never be truly economical and may leave them worse off than before. Large scale farmers may not experience the same worries, but whole communities in Kenya and other countries need to consider what the potential effects of widespread contaminated land and water may be. They also need to consider the consequences of most of their food production being owned by a multinational that is not even bound by the country's laws.

It's worthwhile for Kenyans to bear in mind that cotton industries in developing countries did not decline because of pests and other problems but because a more powerful country controls the market. This is not likely to change quickly and the Americans are not going to give up the level of control that they have cheated so hard to obtain. Similar remarks apply to other GM crops. GM is not a technology for the poor, it is a technology for the powerful, like many technologies. But of course, it's of less use to the powerful unless the poor believe that they too need GM technology.