Treatment as prevention. Another postscript.Posted on April 19th, 2009 1 comment
This additional postscript was prompted by an article that appeared a few days ago in the Washington Post. It was written by Dr Anthony Fauci, who adds his voice to support a policy of universal HIV testing and treatment of all those infected, adding also the treatment of uninfected people at high risk.
He points to the dire situation in DC, and states that our prevention efforts have been insufficient. That is perfectly true. But he, with all of us, have watched this terrible situation developing over the past 20 years; as my first post, AIDS and Minorities indicates, we did little to prevent it.
We get Dr Fauci’s point that probably more than 56,000 Americans have been infected with HIV every year for the past decade. But if we look at the graph in my first post we can see that over the years, the proportion of infections in African Americans rose, while it fell in white Americans, although the numbers have levelled in the past 6-7 years.
So, when we are told that our prevention efforts have been insufficient, are we not really being told that we just neglected or were unable to develop adequate prevention education programs for some populations? Or are we being told that this is inherently an impossible task?
It is not. Gay men were able to make a significant impact of the spread of AIDS in the early years of the epidemic. Safer sex with the use of condoms did make a difference.
Safer sex originated in this community without the slightest outside help. I would also guess that the armies of behavioral psychologists who entered the field found that within this community, essential behavioral modifications had been already learned without much need for their interventions or recommendations.
We might learn something from this experience. Empowered communities can respond to threat, and maybe we should be providing the support communities need to achieve this.
Dr Fauci’s “three pronged” approach is fraught with danger. Firstly it implies that prevention education cannot work. This is very unfortunate as it provides an excuse to diminish, rather than intensify our efforts. We absolutely have not exhausted all the potential there is to create persistent and effective highly targeted prevention education programs. It is possible that with adequate support communities can best do this themselves.
Then there is the problem discussed in an earlier post “Treatment as Prevention” that deals with the many implications of providing treatment to individuals for a social good, but where the treated individuals will derive no benefit themselves.
Infected individuals who do not need treatment will therefore be asked to receive it and thus be exposed to the risks of the drugs but derive no personal benefit from them.
The first of the three bold approaches suggested is the treatment of uninfected people at high risk; this is called pre-exposure prophylaxis (PrEp).
This of course includes sexually active gay men, IV drug users, and heterosexual female and male partners to an infected person. If this means intermittent use of PrEp I would agree that this may well be a useful, if as yet unproven approach. The persistent use of PrEp is another matter as drug toxicity is an issue.
Here it can certainly be argued that the uninfected individual taking antiviral drugs may certainly benefit from their use, unlike the treatment of healthy HIV infected people with higher CD4 counts who may be slow or even non progressors.
For the uninfected individual at risk the persistent use of PrEp is something that individuals should decide on themselves, given adequate information. I doubt whether this will make the slightest difference to the state of the epidemic, but may provide individual benefit.
The multitude of problems associated with the second and third approaches were simply ignored. I will not repeat the problems that exist in treating people, not for their benefit, but for a social benefit; these are discussed in my previous post.
It is far from clear – as the article categorically states that benefit will be derived from starting treatment as soon as possible after infection. There is no direct evidence to support this contention. We simply do not know if very prolonged exposure to antiviral drugs will prolong, shorten or have no effect on an individual’s life span.
As far as toxicity is concerned, it is often stated that the newer drugs are less toxic. How on earth do we know this with only a few years use? We have enough experience of severe toxic effects only being recognized after years of use. The drugs that block the HIV co-receptor are particularly worrisome. CCR5 does not exist on the cell surface for the convenience of HIV. It serves a physiological function and time will tell if blocking its natural function has deleterious effects, and if these outweigh the benefits the drugs confer in inhibiting HIV replication.
As far as eradication is concerned – which appears to be the third new bold approach, this possibility is so far in the future, if it ever can be achieved, that it is absolutely unrealistic to base any practical policy on its success. The difficulties in killing all cells that harbour stable integrated HIV DNA, or of excising it from the human genome are enormous.
Before undertaking such a “three pronged” project we would need some assurance of success; we would need to know, for example what degree of compliance would be necessary for it to work. But these issues are discussed in my previous post.
At the moment the only winners in this approach will be the drug and testing equipment manufacturers.
We should renew and redouble our efforts towards producing and persistently disseminating prevention education messages, appropriately targeted to specific populations. We should provide communities with adequate support so that they can craft their own prevention education materials, and disseminate them.
We should remove all barriers to testing. This includes the most difficult of undertakings which is to fight the stigmatization still associated with this disease.
This will entail an avoidance of policies and legislation that have the effect of increasing stigmatization. Among other disincentives to testing is the lack of assurance of a link to medical care. The cavalier approach to informed consent recently demonstrated by some providers and community groups is misguided:
It is likely that the consequences of “streamlining” the consent process for testing will actually have the effect of dissuading individuals from being tested.
Those proposing “streamlining” the consent process may think HIV testing is routine. Those testing positive may soon come to a different conclusion when they learn that HIV disease is serious, can be associated with stigmatization, treatments may not be affordable or available, may have adverse effects, jobs may be lost, and families may abandon infected individuals.
Can a test that opens the door to such difficulties be regarded as routine?
As long as these consequences of testing remain possible, we absolutely must obtain informed consent for testing so that our patients will know of the implications of both a negative and positive test. We all gain from doing everything possible to be supportive and retain the trust of our patients. This will not be achieved by misleading them.
In conclusion: Providing antiviral drugs to people who do not need them is no substitute for developing a variety of highly targeted prevention education strategies.
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