Time to Prepare for “PrEP”

It all began with a 1994 study that showed antiretrovirals given to HIV-positive pregnant women before and during childbirth – as well as to the child upon delivery – reduced the risk of mother-to-child HIV transmission by 50%. Next were the post-exposure prophylaxis guidelines issued by the Center for Disease Control and Prevention in 1998, recommending an antiretroviral regimen for healthcare workers after unintended HIV exposure. Then, 2006 brought exciting data gleaned from a study of monkeys who remained uninfected after repeated exposure to a HIV-like virus as a result of taking the antiretroviral drugs tenofovir and emtrictabine. These studies raised the question: Can drugs prevent HIV? After recent unimpressive results in vaccine and microbicide tests, scientists’ leading hope for stopping HIV infection before it starts seeks to answer that question with pre-exposure prophylaxis, or PrEP.

By the middle of next year, close to 15,000 individuals will be enrolled in PrEP trials. That’s more people than all HIV vaccine and microbicide trials combined. In the PrEP approach, an oral antiretroviral agent (specifically, Viread or Truvada) is taken daily to prevent HIV infection. In theory, this method inhibits HIV replication and permanent infection from the moment the virus enters the body. If proven safe and effective, PrEP could significantly reduce the risk of HIV infection for high-risk individuals all over the world. It would be particularly advantageous for individuals in serodiscordant relationships as well as those unable to negotiate other proven protective measures such as condom use. Perhaps most importantly, PrEP would represent the first female-initiated intervention method.

Currently, three studies conducted by the CDC are underway to test the safety and effectiveness of PrEP. In Thailand, injection drug users are using once-daily Viread. In Botswana, young heterosexual men and women are taking once daily Truvada, and in the US, once-daily Viread is being tested among men who have sex with men.

PrEP is quickly becoming a reality. Over the course of 7 years, the CDC will spend an estimated $53 million researching PrEP. Most importantly, the CDC has recently urged public health leaders to begin planning for PrEP implementation. The time has come to discuss the optimal use and delivery of PrEP if found effective. PrEP raises particularly challenging questions that need attention now. How will we ensure that individuals use PrEP in concert with other proven preventative strategies? Some people may refuse to use condoms if they learn that their partner is taking PrEP and, theoretically, protected from HIV transmission. No single strategy will likely be 100% effective against HIV infection, and reducing transmission will require integration of all biomedical and behavioral methods. How will healthcare providers ensure that PrEP is used before exposure, and not after infection, to prevent drug-resistant HIV? Who exactly would be prescribed PrEP? Would people be required to prove that they are at "high risk," and if so, will that lead to their being stigmatized? What will happen if an individual disregards instructions for daily use and takes the pill before a night on the town? Will this ineffective so-called “disco dosing” become rampant? Already, rumors are emerging of new drug cocktails of Truvada, Viread, Viagra and Ecstasy that are being sold in gay dance clubs.

Clearly, this new strategy will not be a panacea for the difficult issues involved in the HIV pandemic, including stigma, the sexuality of young people, drug use, homophobia and the sex industry. PrEP may one day be an important response to AIDS, but that response will never be equitable nor ultimately successful unless we begin planning for it now.

I’m Charlotte Steelman. Thanks for listening.

New Leadership in South Africa brings hope for AIDS Reform

72% of the 5.5 million South Africans who are HIV-positive are in need of antiretroviral (ARV) drug treatment. In leading the movement against ARV drugs, recently removed South African President Thabo Mbeki denied millions of his people HIV treatment. He believes that the AIDS pandemic was created by Western pharmaceutical companies to take advantage of Africans and maximize their profits. Mbeki also sides with dissident scientists in denying that the HIV virus causes AIDS and in 2003 he was quoted as saying, “Personally, I don’t know anybody who has died of AIDS” and when asked if he knew anyone infected with HIV he responded, “I really, honestly don’t”. Mbeki’s views opposing antiretroviral drugs were echoed by his Health Minister, Manto Tshabalala-Msimang, more commonly known as “Dr. Garlic”, who promotes garlic, olive oil, beetroot, and African potatoes as a cure for AIDS.

Because the South African government has been reluctant to supply its people with antiretroviral drugs, HIV/AIDS activist groups, such at the Treatment Action Campaign (TAC), have been instrumental in the push to allow the distribution of these drugs. It was not until 2004 that the South African government, pressured by HIV/AIDS activist groups, finally began to provide ARVs for its people. It also took a Constitutional Court battle and much lobbying from the TAC to compel the Health Department to allow the administration of AZT and nevirapine to HIV-positive pregnant women to prevent mother-to-child transmission of the virus.

However, the recent resignation of Mbeki as President of South Africa and the September 25th appointment of the ruling African National Congress (ANC) deputy head Kgaleme Motlanthe as interim president, give HIV/AIDS activists hope for change. His first day in office, Motlanthe demoted “Dr. Garlic” to a less important Cabinet position and appointed Barbara Hogan, a senior ANC member of Parliament, as Minister of Health and Dr. Molefi Sefularo as Deputy Minister of Health. The TAC applauded Motlanthe’s change in administration and issued a statement in support of the new appointees. The TAC credits Hogan as being “one of the few Members of Parliament to speak out against AIDS denialism and to offer support to the TAC” and cites Dr. Sefularo as supporting “ARV rollout and the implementation of the Prevention of Mother to Child Transmission” at Health of North West Province.

Hogan has already promised to “champion the issue” of the government increasing spending on providing ARVs to HIV-positive individuals. In an interview just hours before being sworn into office, Hogan was quoted as saying, “I would thoroughly endorse the roll-out of anti-retrovirals and any way that we can accelerate that, the better”.

Looking ahead to the next president’s administration, in the most recent edition of the ANC newsletter Jacob Zuma, current ANC President the expected future South African President, is quoted as wanting “more action with regards to the reduction of HIV infections…widespread HIV prevention, treatment and support programmes”. Yet, Zuma’s infamous statement during his 2006 rape trial that he showered after intercourse with a HIV-positive woman to minimize the risk of becoming infected lingers in the back of my mind. I question that how such change can be implemented when South African government officials still need to be educated about how HIV is transmitted and how to reduce their risk of infection.

World AIDS Day – The Power of One

Today is the 20th annual World AIDS Day, a day set aside to remember those who have died of HIV/AIDS and those who are living with HIV/AIDS. It’s also a day to remind ourselves that we all are affected by this disease. Today, many of us are wearing red ribbon pins. Many of us have placed red ribbon photos on social networking sites. Many of us will be attending HIV/AIDS breakfasts or seminars. Many of us are blogging about HIV/AIDS.

Do any of these events really matter? Roughly 35 million people worldwide are infected. 14,000 people become newly infected every day. Will wearing a red ribbon or attending a breakfast change that? Sometimes, the pessimist in me says no. But then I look around at the various activities going on and think differently. Never underestimate the power of small actions. Never underestimate the power of one.

At Davidson College, groups of students are making a difference. For several years now, the members of Warner Hall, a women’s eating house at Davidson, have hosted the Red and Black Ball, a charity event for HIV/AIDS. This year, the proceeds will benefit Metrolina AIDS Project in Charlotte and Thyatira
Hospital in Mwandi. The members of Warner Hall also help Metrolina AIDS Project in other ways. Recently, I joined them on a Saturday morning to make condom packets – small bags containing condoms and information about getting tested for HIV – to be distributed at local bars and clubs.

Students at Davidson College make condom packets for Metrolina AIDS Project

This effort, though, is not solely an extracurricular activity. In a mutually beneficial partnership, the students in my Biology course on HIV/AIDS cooperate with Warner Hall on some of these projects. Together, we have sponsored screenings of movies like 3 Needles, volunteered at a local HIV/AIDS benefit triathlon, collected toys for the annual Metrolina AIDS Project holiday party, and organized speakers and symposia. Academic and extracurricular activities are wonderfully joined.

Volunteers getting ready for their assignments at a triathlon to benefit Metrolina AIDS Project

None of these events, individually or even in total, will end the AIDS Pandemic. But each and every one of these events does make a difference. Maybe one person will receive a condom packet and, as a result, not become infected. Maybe the money sent to Mwandi will help provide care for a child in need. Maybe one person who listens to a seminar will enter a career of public service. Maybe all of us will be a little more aware.

Today, I’m wearing my red ribbon. Today, I’m blogging about HIV/AIDS. Today, I’m attending an HIV/AIDS breakfast. Today, in some small way, some almost imperceptible way, I’m making a difference. We all can make a difference. Never underestimate the power of one.