Greetings my fellow Kossacks! Today GLBT and Friends at Daily Kos have asked me, FogCityJohn, to deliver a special report on recent news in the world of HIV/AIDS. As some of you may know, I'm HIV+ and a blogger at TheBody.com, one of the nation's largest HIV websites, so HIV is an issue near and dear to my heart.
It's been a big week or so on the HIV front. President Obama released the National HIV/AIDS Strategy for the United States. In addition, the XVIII International AIDS Conference wrapped up today in Vienna, Austria. So I'm very pleased to have the opportunity to share some of the news with you.
One thing I should clarify before we begin, though. While GLBT and Friends have graciously allowed me use of their account for this diary, all editorial commentary and opinions expressed herein are mine and mine alone. They do not necessarily represent the views of GLBT and Friends at Daily Kos or of any other member of our group.
So with that caveat, let's make the jump!
I. President Obama Releases the National HIV/AIDS Strategy for the United States.
While there's lots going on in HIV this week, the biggest news from a domestic policy standpoint was the Obama administration's release of the National HIV/AIDS Strategy for the United States (pdf) on July 13th. The president delivered a speech at the White House to commemorate the event. The NHAS is the first national plan for dealing with HIV/AIDS since the epidemic began 30 years ago. That Barack Obama is the first American president to adopt a national strategy for responding to HIV already tells you something about our government's historical indifference to this disease.
The strategy's "vision statement" says:
The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.
(As my late friend Richard used to say, "From your lips to God's ears.")
There is much to like in the strategy. Its four broad goals are (1) to reduce new HIV infections, (2) to increase access to care and improve health outcomes for people with HIV, (3) to reduce "HIV-related disparities and health inequities," and (4) to achieve a more coordinated national response to the HIV epidemic. To these ends, the NHAS advocates such things as "evidence based" approaches to prevention, directs that priority be given to communities at higher risk for HIV (such as gay men and African-Americans), and calls for combatting HIV stigma. All of this is laudable, and as a result, the NHAS was met with praise in most quarters. (TheBody.com has a collection of reactions from the advocacy community.)
The praise was guarded, however, since the NHAS does not commit any new resources to the fight against HIV. As noted in the executive summary, "The Strategy is intended to promote greater investment in HIV/AIDS, but this is not a budget document." Phill Wilson, President and CEO of the Black AIDS Institute summed up the attitude of many HIV activists and AIDS service organizations:
Unfortunately, the new strategy does not sufficiently address the issue of resources. Already, we are seeing many AIDS drug assistance programs impose caps or waiting lists for life-saving drugs. There are over 3000 people on ADAP waiting lists. This month, the President authorized a one-time funding increase for ADAP of $25 million, but this amount, while welcome, represents only about 7% of amounts needed this year alone to ensure the program's continued solvency.
At a time when we are largely losing the fight to prevent new infections, prevention programs currently account for only 3% of federal AIDS spending. To put available prevention weapons to effective use, experts estimate that annual prevention spending needs to increase from $750 million to $1.3 billion for at least each of the next five years. This new strategy offers a sound, evidence-based approach to better results, but it will be worth little more than the paper it is written on if we don't follow through with essential resources.
Obama himself framed the question perfectly in his remarks on the release of the strategy:
So the question is not whether we know what to do, but whether we will do it. Whether we will fulfill those obligations; whether we will marshal our resources and the political will to confront a tragedy that is preventable.
When I asked one member of the AIDS Treatment Activists Coalition for her thoughts on the NHAS, she said simply, "Show me the money." Indeed. We will now see whether the administration will put its money where its mouth is.
II. The XVIII International AIDS Conference
The other big news on the HIV front this week is, of course, the 18th International AIDS Conference, which ended today in Vienna. The IAC brought together more than 20,000 delegates for a series of presentations on issues ranging from the basic science of HIV, to treatments, to policy and prevention. Of course, delegates weren't the only ones who made it to the conference, and AIDS activists from around the world demonstrated to demand that governments keep their promises on fighting the epidemic:
Both TheBody.com and aidsmap.com. are offering detailed coverage of the IAC, so check out those sites for more information. The entire conference program is also available on line. Here are a few items for the conference that struck my interest:
A. HIV Prevention
Not Yet Gelled
One of the biggest pieces of news from the conference were the results of a South African study showing that a microbicide gel prevented four out of ten HIV infections (39% efficacy), and prevented more than half of the infections in women who used the gel more than 80% of the time (54% efficacy).
The gel contains the antiretroviral medication tenofovir (brand name Viread), which is a component of two commonly used combination drugs -- Atripla, which is currently the only once-a-day medication for HIV, and Truvada, a two-drug combination pill that forms the "backbone" of many combination therapies. Anthony Fauci, director of the National Institute of Allergies and Infectious Diseases, called the results "really enormous," but Catherine Hankins, chief scientific advisor to UNAIDS, warned that microbicides containing a single HIV drug should never be used by a person with HIV until we know a great deal more about whether it could cause resistance – though there was no sign of resistance in this particular study. I recently discussed this study with Dr. Jay Levy, one of the world's leading experts in HIV, and he agreed that use of tenofovir alone in such a gel could lead to the development of HIV strains that are resistant to the drug. Since tenofovir is a component in so many widely-used antiretroviral combinations, much more work will be needed before such a gel will be safe for general use.
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Not So Rotten in Denmark
A Danish study showed the HIV transmission rate among gay men and men who have sex with men (MSM) in the country appears to be falling even though the number of people living with the virus continues to increase, and despite high levels of unsafe sex. More than 80% of MSM diagnosed with HIV are on antiretroviral (ARV) treatment and 85% of them have an undetectable viral load. ("Viral load" refers to the number of "copies" of HIV circulating in a milliliter of blood plasma.) The number of infections newly diagnosed in gay men had increased per year from 1000 in 1995, to 1500 in 2001 and 2200 in 2009. With a very low death rate, this meant that more and more gay men in the country had HIV. Furthermore, there are very high levels of unsafe sex among gay men. The percentage of HIV+ men who had had unprotected anal sex with someone who had or might have had a different HIV status was 37% in 2001 and 64% in 2009. Despite this, the proportion of gay men who transmitted HIV during any one year has steadily declined. The most likely explanation for this paradox is the higher proportion of HIV+ men who are on HIV treatment and have undetectable viral loads are never or very rarely transmitting HIV.
In other words, getting HIV+ people on effective antiretroviral treatment that lowers their viral loads to undetectable levels also makes them far less likely to transmit HIV to their partners even if they have unprotected sex. Just one more argument for getting everyone with HIV onto treatment.
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Data Entry
Microsoft founder Bill Gates addressed HIV prevention at IAC, and he presented models that showed that we could cut current epidemics by 40% with the efficient and targeted use of simple prevention resources we have already. According to Gates:
The problem is not lack of data. The problem is that countries are not using the data to make funding decisions. Instead politicians are making decisions based on fear and stigma.
Correctly targeted interventions, including behavioral interventions that are properly focused and researched, might cut the global epidemic in half, Gates said.
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"Cutting" the Transmission Rate?
Mathematical models presented at IAC found that male circumcision, used alone or in combination with other prevention methods such as microbicides could have a modest effect in reducing rates of HIV transmission. According to aidsmap:
The models, by Andrew Cox of the London School of Hygiene and Tropical Medicine and Hiam Chemaitelly of Weill Cornell Medical College in Qatar, broadly agreed that a realistic level of microbicide and circumcision adoption would produce an approximately 20% reduction in new HIV infections within 15 to 20 years. Adding comprehensive antiretroviral therapy (ART) into this mix would reduce new infections considerably more.
A third model, by Geoffrey Garnett of Imperial College in London, was cited by Bill Gates in his conference talk on Monday. This showed that adding in microbicides and pre-exposure prophylaxis (PrEP) to currently available prevention interventions – excluding ART – would reduce HIV infections by an additional 15 to 18%.
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B. Law and Policy
Big Bill
The Big Dog himself gave a speech in which he claimed we are at the "end of the beginning" of the AIDS epidemic. The primary subject of Clinton's speech was how to achieve greater financial efficiency and economy of scale in a situation in which global AIDS funding was likely to be held static for the next couple of years. Clinton addressed the cost of HIV medications in the developing world, and he expressed doubt that the annual cost of drug regimens could be lowered from the current $90 for first-line therapies and $435 for second-line therapies.
(Just an aside. For those of you who think PhARMA isn't making a killing on drugs in this country, please note that the cost of my three-drug combination therapy, which consists of the drugs Truvada and Isentress, is $1,300 per month.)
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Crime and Punishment
We should all be happy to know that North America and Western Europe lead the world in criminalizing HIV exposure. Since we Americans so intent on being number one, it bears pointing out that:
The United States is also notable for prosecutions of HIV exposure being brought when a low or zero risk activity was involved (for example, biting or spitting), for issuing severe prison sentences and for introducing HIV-specific laws (in 24 states).
(Seems like President Obama will have his work cut out for him if he's serious about achieving the NHAS's stated goal of eliminating HIV stigma.)
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Shown the Door
According to a survey conducted by Deutsche AIDS-Hilfe (a Germany-based HIV education and advocacy organization) and Human Rights Watch, at least 31 countries still deport people living with HIV. The following countries surveyed said they deported people with HIV:
In alphabetical order, these countries are Armenia, Bahrain, Bangladesh, Brunei, Egypt, Equatorial Guinea, Hungary, India, Iraq, Jordan, Kazakhstain, Korea (North and South), Kuwait, Malaysia, Moldova, Mongolia, Oman, Panama, Qatar, Russia, Saudi Arabia, Singapore, Solomon Islands, Sri Lanka, Syria, Taiwan, Turkmenistan, United Arab Emirates, Uzbekistan and Yemen.
C. HIV Research
The Cure
Sharon Lewin of Monash University in Melbourne, Australia, told the conferees that a cure for HIV infection is scientifically feasible and increasingly necessary, but the goal requires focus and funding. Lewin also discussed the costs of treatment. According to aidsmap:
Lewin noted that even treating the current 40% of HIV-positive people in low- and middle-income countries starting at the old World Health Organization CD4 threshold of 200 cells/mm3 would cost $25 billion by 2030, whilst increasing coverage to 80% would raise that figure to $35 billion.
(Gee, $35 billion? That's less than one war supplemental.)
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Control Queen
One area of HIV research that has been getting more attention in recent years is the investigation of so-called "HIV controllers." HIV controllers are a subset of HIV infected individuals who are able to keep the virus from replicating without the aid of treatment. About 1 out of every 300 infected persons is an HIV controller. My friend and fellow blogger at TheBody.com, Loreen Willenberg, has been blogging this week about the IAC research presentations focused on this small and unique group of people.
Loreen herself is what's termed an "elite controller." She's been HIV+ since 1992 and has never had a detectable viral load. In addition, her CD4 immune cell levels are actually higher than those found in HIV-negative people. Researchers are busily trying to figure out how Loreen and others like her suppress the reproduction of HIV naturally. In addition to blogging and serving as a research guinea pig, Loreen is also president of the Zephyr Foundation, a non-profit she created to help facilitate research participation by HIV controllers. Check out her blog for her explanations of the IAC presentations on HIV controller research.
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A Failure to Communicate
Reporting on findings that will surprise few people with HIV, Tim Horn at aidsmeds.com calls attention to a survey presented at IAC that found many HIV+ people and their health care providers are not communicating effectively about critical health-related conditions. Horn writes:
The survey also found that less than one third (28 percent) of respondents had discussed their family history of [cardiovascular disease (CVD)] with their health care providers, and 65 percent of respondents who qualified as high-risk for CVD were not engaging in frequent discussions related to heart disease with their physicians. . . .
Meanwhile, 44 percent of these respondents had never discussed the effects of smoking with their health care providers.
ARV [medication] side effects were also being left out of patient-physician conversations. While 40 percent of respondents claimed that they do not like the way their medications make them feel, most notably in Europe and the Asia-Pacific regions (both 42 percent), and 50 percent said their medications have had a somewhat to extremely negative impact on their lives, nearly one quarter had never spoken to their health care providers about side effects they are currently experiencing.
My personal take on this one -- we poz folks don't discuss lots of things because our physicians have a tendency to ignore what we say. Just my $0.02.
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III. Micellaneous HIV News
Obviously, NHAS and IAC have dominated the headlines in the HIV arena over the past week or so. But that shouldn't obscure the fact that there were developments on other fronts. Here's a sampler:
ADAP-ting
The crisis in funding for state AIDS drug assistance programs (ADAPs) continues. The Obama administration announced it would offer $25 million in additional ADAP funding to hard-pressed states, a figure that the National Association of State and Territorial AIDS Directors (pdf) says is a fraction of the $126 million needed for FY2010 just to keep ADAPs at their current enrollments. So New Jersey is kicking 950 people off of its ADAP rolls, Texas is warning of cuts, and 320 HIV+ Ohioans have been informed that they'll lose access to their meds due to budget tightening.
As of July 15, 2010, there were 1,879 people on ADAP waiting lists across the country.
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Survey Finds That "Water Is Wet"
Just couldn't resist this one. I'm shocked, shocked to learn that 40% of U.S. adults say fumbling with a condom dampens the mood for sex. This according to United Press International, which reported the results of a survey conducted by a Miami-based condom manufacturer.
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Thanks for reading. There's a whole lot more coverage of the conference at the links provided, and I urge everyone with an interest in HIV to take a look.
Okay, I'm out.
FCJ