JONATHAN COHN NOVEMBER 23, 2010
We live in discouraging times. The economy is in deep recession. Republicans won major midterm election victories. North Korea is acting crazy. Iran may develop a nuclear bomb.
Fortunately, not everything is bad news. In the world of HIV prevention and care, this has been a season of hope and breakthrough that deserves greater attention. Today’s New England Journal of Medicine includes an important paper, “Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men.” I can’t provide all the details here. You should read the accompanying New York Times story and then actually read the study, which was conducted with admirable craftsmanship and ingenuity.
This large NIH and Gates-funded study was conducted in six countries by the iPrEx Study Team. They randomly assigned 2,499 HIV-negative men or transgender women to either a standard-care control group (who received safer-sex counseling and other standard services) or to a treatment group which received the same services but also received oral anti-retroviral drugs. The bottom line: Members of the treatment group experienced a 44 percent reduction in the rate of HIV infection. Moreover, the protective effect appears to have been much larger among people who faithfully took the medications. Only 3 out of 34 HIV-infected subjects had detectable levels of anti-retrovirals in their blood streams.
(Why would study subjects fail to take potentially life-saving medications? Some people are deterred by side-effects such as nausea and headache. And the life circumstances of individuals at highest HIV risk are not always conducive to reliable medicine-taking. As the Time’s Donald McNeil shrewdly notes, some study subjects stop taking their medications because they rightly or wrongly determine that they were given placebo.)
These favorable results come on the heels of other positive results. For many years, researchers have searched for effective microbicides to protect at-risk women and men. That search produced a long stream of failures and disappointments. Some promising microbicides turned out to actually increase the rate of new infections.
This fall, Quarraisha Abdool Karim and colleagues in the CAPRISA 004 Trial Groupshowed that Tenofovir gel could reduce HIV incidence by 39 percent among high-risk South African women. Again, microbicide offered greater protection to women who closely followed the recommended treatment. It was also no magic bullet. HIV incidence among study subjects remained agonizingly high. The microbicide reduced the annual rate of new HIV infections from 9.1 per 100 person-years to 5.6. This still represented huge progress, from both a human and a scientific perspective.
These microbicides, oral antiretrovirals too, are especially important because they offer an avenue to risk-reduction among vulnerable people who may not be in a position to demand that their sexual partners use condoms or that their spouses remain monogamous. That's a sadly necessary dimension to the prevention challenge.
Just today, UNAIDS announced that "At least 56 countries have either stabilized or achieved significant declines in rates of new HIV infections." HIV mortality rates have declined by nearly 20 percent since 2004. That's about 300,000 prevented deaths every year. Even Pope Benedict has unexpectedly opened a useful door with his recent comments that condom distribution is sometimes justified under Catholic doctrine to prevent HIV.
The United States and other wealthy countries should do much more—despite our current economic traumas—to help in the fight for life against a host of global health threats. One thing we fight against is the sense that there's just nothing we can do.
Every day, tens of thousands of people put the lie to that despairing, ultimately lazy formulation. Medical and public health communities around the world are making great progress against HIV, malaria, infant mortality, and many deadly diseases. There's a lot we can do. This is no time to let up.
Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago.