September 18, 2012 The Pump Handle 4Comment

By Sara Gorman

Recent biomedical advances in AIDS research have allowed political figures such as Secretary of State Hillary Clinton to proclaim that the phenomenon of a generation without HIV/AIDS is within reach. But how well-founded is this optimism? A recent editorial in The New England Journal of Medicine asks this very question and concludes that there is ample reason for scientific optimism but that the global resources needed to achieve the eradication of this illness are simply not being deployed properly.

Yet the science itself does not indicate that the possibility of the eradication of HIV/AIDS is immediately within reach. A vaccine for HIV proved successful in one trial in Thailand, but this is not enough to proclaim victory over the illness. At the same time, research on pre-exposure prophylaxis has proven encouraging and effective in some populations, but there is still a long way to go to establish the safety of these measures as well as their effectiveness in all populations affected by the epidemic. What’s more, certain social and socioeconomic factors still remain a serious barrier to care globally, and we cannot be exceedingly optimistic about the availability of novel treatments until we can ensure that people will actually have access to them.

Much of the scientific optimism about the possibility of eradicating HIV/AIDS derives from the July 16 2012, FDA approval of Truvada (emtricitabine and tenofovir disoproxil fumarate) for daily use as a prophylactic agent against HIV/AIDS. The approval stems from a series of recent studies, some of which demonstrate the efficacy of the drug in preventing HIV/AIDS when used prophylactically. The drug has been shown to be highly effective for prophylactic use in MSM (men who have sex with men) and among heterosexual men. Yet one study conducted in Africa suggests that Truvada for pre-exposure prophylaxis (PrEP) may not be an effective means of preventing HIV/AIDS among women. Researchers found no significant reduction in HIV-acquisition among women taking Truvada compared to the placebo group. The study begs the question of whether more research is needed before women start utilizing Truvada as a reliable prophylactic measure.

Several negative effects of the FDA’s approval are also possible. It remains to be seen whether provision of Truvada for PrEP diminishes use of condoms and other safe sex measures, contributing to a potential increase in STI’s other than HIV/AIDS. The emergence of antiretroviral-resistant strains of HIV/AIDS should be carefully monitored, even though one study of Truvada for PrEP reported low rates of newly resistant strains. Other drugs with lower potential for development of resistant strains, such as maraviroc-based drug regimens, should be tested widely, among heterosexual men and women as well as among men who have sex with men (MSM). Although the FDA’s approval is a step in the right direction, too much optimism can lead to complacency when more research, and more funding for more research, are still desperately needed.

Yet even in the probable event that our scientific optimism proves justified, the question remains: how should limited resources best be deployed? It is clear that there is still much need for funding for scientific studies in pursuit of an AIDS vaccine and for cheaper and safer drugs for PrEP that work in all populations. Yet it is equally important to evaluate the sub-populations in which the epidemic is growing or most recalcitrant and to provide these populations with better access to prevention and treatment. In the United States, rates of HIV/AIDS are actually rising in some populations, including young racial minorities and African American women. There is a growing HIV/AIDS crisis outside of urban areas and in the American South. One of the greatest challenges to reducing transmission rates is poor access to medical care. Low-income individuals, and especially women, with HIV/AIDS often go without medical care due to transportation challenges and competing needs such as childcare responsibilities. Investment in federal aid programs that provide social support for individuals with HIV/AIDS in the U.S. may go a long way in curbing transmission rates. Funding for similar programming globally must also be implemented.

There is in fact much cause for optimism about the possibility of the eradication of HIV/AIDS in coming generations. But we should be sure not to become too secure and complacent in the progress currently being made and take careful inventory of what remains to be done.

Sara Gorman is a PhD candidate at Harvard University. She has written extensively about HIV, TB, and women’s and children’s health for a variety of public health organizations, including Save a Mother and Boston Center for Refugee Health and Human Rights. She most recently worked in the policy division at the HIV Law Project.

4 thoughts on “Optimism and the HIV/AIDS epidemic

  1. Great analysis. Yes, it’s one thing to be optimistic about the scientific advances to control and potentially eradicate HIV/AIDS. Opinion leaders and policy makers have a duty to temper that optimism with factual information explaining why such advances are not a magic bullet.

  2. An awful presentation of findings. The vaccine trial in Thailand could hardly be called successful, certainly not enough to lead to dissemination of the products that were tested. The PrEP trials that failed mostly did so because of adherence, which may have been related to the difficulties in making sure a topical product delivers a viable dose. there is still much to do in demonstrating whether different kinds of transmission are more or less sensitive to biological prevention (injection being a more potent and direct biologic challenge, anal sex being very different from vaginal sex). Adherence is an issue for any biomedical modality and it’s easy to stop using something in the absence of symptoms. Long-acting formulations are needed, but those kinds of dosing schedules may have their own limitations.

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