A look at HIV treatments in a global context

HIV/AIDS: An introduction

World AIDS Day is Dec 1st
Every Year

As most of us know by now, the Human Immunodeficiency Virus (HIV), has become a pandemic of epic proportions.  Lower income countries, and many underserved parts and populations of the United States, still continue to struggle with the disease, and with proven strategies to decrease incidence rates—even with the many advancements and understanding of HIV that we have in certain sectors of the developed world and globally. In an attempt to understand the disease and how it impacts many different populations across the world more in-depth, several of our group members watched 3 Needles: a 2005 Canadian film released on World AIDS Day. You can see the trailer for the film below. This film, along with the links, are a good primer for understanding the global HIV epidemic a bit more. After watching the film several of us became interested in understanding what is being done now, and what sort of interventions can be successfully deployed to combat this disease around the world.

Pharmacological Interventions: (You down with A-R-T?!)

Lesbian, Gay, Straight, Bisexual: doesn't matter.
Get tested.

A good number of our group members focused on pharmacological interventions, since it is recommended by one of the leading authorities on global health and HIV, the World Health Organization. As our technology improves, the cost of creating medications and delivering those medications to at-risk populations goes down. (It should be pointed out though that often in the developing world, and some in the developed world, the problem lies not in the medications, or the cost of medications, but having infrastructure in place to deliver medicines effectively to populaitons: as well as many populations having members that do not get tested for a variety of reason.) As the cost of getting those medicines in the hands of the masses goes down, perhaps we can start seeing more cases like the recent HIV 'cure' baby in the United States, and perhaps other countries that employ a system of a health care like our own. 

In the case of the toddler, antiretroviral drugs, (also known as ARVs,) were used in combination with counseling and helping the parents. When ARVs are used in conjunction with counseling, this is called antiretroviral therapy, (or ART).  A key part of the popularity of ART as a treatment and prevention strategy has been the development new types of drugs around the world. Before development, the first, the only—and most expensive drug—was AZT which carried some pretty hefty side effects.  Now, AZT is used in combination with other ARVs that help combat the virus, and stop it from becoming AIDS.

Treatment as Prevention: (PrEP up, PEP up)

A recent report found that 25% of new infection rates
 among gay men was in serodiscordant relationships.

One of the things that WHO calls for is the increased use of a model of intervention known as "treatment as prevention". This model advocates for those who are living with HIV to take ARVs as a way to decrease the amount of disease present in their system, or "viral load", and therefore reduce the risk or chance they pass on the virus to a sexual partner. The treatment of prevention model has been primarily used in the West but, thanks to medical advancements, it's quickly being spread to the rest of the globe, and being herald as one of the silver bullets in combating the epidemic.

While most of Treatment as Prevention calls for the treatment of the HIV+ person, there are some ARTs that are targeting those who are HIV- but may have or had sexual relationships with people with the virus. In couples in which one partner has HIV and the other doesn't, (also know as serodiscordiant couples,) the use of Pre-Exposure Prophylactics has been shown to be highly effective. This is particularly good for those who have high rates of HIV transmission within their communities, like IV drug users, and gay/bisexual men who have sex with men, which are two groups who around the world are often ignored and/or ashamed to seek treatment.

Another way to utilize ARVs is in Post Exposure Prophylactics. PEPs were originally used strictly in an occupational (oPEP) sense for medical personel that may have been exposed to the virus, (doctors, clinicians, ect), but are finding a stronger foothold in non-occupational (nPEP) places. PEPs are a treatment that becomes really important in treatment of HIV among populations that have a higher frequency of being exposed to sexual assault and risky sexual behaviors like sex workers, who are often at an increased risk as a country's GDP begins to improve. Several studies have looked at how to incorporate sex workers as key actors in the fight against global HIV incidence: PEP may go a good way to making sure that sex workers, and other community members, are protected.

Adherence: (Sticking it to the [HIV])

Dr. Robert Gross is hoping to improve patient adherence
with community accountability and collaboration.

While there are many critiques of the Treatment as Prevention model, even down to the name, it has proven to be effective in reducing the risk of transmission amongst high-risk populations. But that is only if HIV+ folks stick to their regimens as well. Adherence to an ART schedule can be very difficult for a variety of reasons, especially if time constraints and hectic lifestyles are taken into consideration. Often times, adherence depends on other factors as well, like the relationship one has with their doctor.

Even in places where doctors, nurses, or other health practitioners are not present, having a person that has a significant relationship to the client help with medicine administering helps with adherence. We've seen this model work, in class, with DOTS and TB. One doctor is currently developing a system that utilizes very similar protocols for adherence with ARTs in Sub-Saharan Africa, where the disease has wreaked much havoc. If he is successful, it would change the way clinicians and health workers approach dealing with HIV/AIDS in the world, perhaps utilizing the whole communities in an effort to arrest the incidence rate in countries around the world.

(This has been a Group 10 blog post.)