Two cheers for lower HIV incidence

UNAIDS published its annual Report on the Global AIDS Epidemic last week, and there is much to celebrate.  The 2012 numbers show a 52% decrease in the number of new HIV infections among children since 2001, and a combined reduction among children and adults of 33% over the same period.  In addition, TB-related deaths for those with HIV has declined 36% since 2001. This has led some in the media -- not UNAIDS, official agencies are more cautious -- to speak of a turning point, a possible end in sight of this epidemic. How did this come about? Probably a number of factors, where it is hard to pinpoint any crucial initiative or cause. The numbers of persons started on antiretroviral treatment has increased sharply over the last decade, and consistent use of antiretrovirals makes HIV-positive persons far less likely to spread the virus to others. But this is only a piece of the puzzle: for now, what we know is that there are falling numbers of infected persons, not so much precisely why they are falling.

Of course, any story of a steady march to epidemic control is likely to conceal less triumphal elements. UNAIDS itself admits that while it is committed to reducing the human rights abuse (particularly in regard to women and other vulnerable groups) that often accompanies HIV infection, there is no sense that we have seen equally substantial reductions in violence against women and children or in excessively punitive laws against injection drug users. And there is more: while UNAIDS cites successes, it does so selectively: the infection rates among men who have sex with men has not deceased over the last decade, to the contrary. Why, ask gay rights groups, is this not emphasized in the press releases? Do the rising infections of gay men matter less than the lowered HIV acquisition among kids and non-gay men? In addition, only a percentage of those in need of HIV treatment in low-income countries are receiving it, and much needs to be done to get close to universal coverage.

As I have mentioned before, the vast numbers of HIV-positive persons on antiretroviral therapy worldwide is an amazing, fragile and contested achievement. Amazing, because there is almost no historical precedent for the magnitude of efforts and funds thrown at this particular disease. Fragile, because if the money streams to keep millions on this lifelong life-saving therapy dry up, and there is a massive treatment interruption, all (possibly drug-resistant) HIV will break loose. Contested, because it is hard not to notice that the investment in HIV/AIDS is disproportional to what is devoted to other diseases that produce similar or worse morbidity and mortality numbers. There is, of course, no ethical way of going back. Just ethically messy ways of pushing forward.

Going off HIV treatment in Tanzania

The ability to manage HIV with antiretroviral treatment, and turn it into (something like) a chronic disease, obviously constitutes important medical and public health progress. Before that, the only alternative was wasting and death. But it is normal that humans adapt to progress, and look for something better. After all, on closer inspection, HIV treatment may not be all it is cracked up to be, particularly as it plays out in low-resource countries. There may not be opportunities to receive the diagnostics that are needed inform optimum treatment. You may be switched from one treatment regime to another without any real medical justification. Patients may have some serious side-effects with certain medications, which may not be the drugs of choice in the better-off countries. And all too often, the supply of antiretroviral drugs may just plain run out. In the greater scheme of things, this fragile dependence on HIV drugs in order to survive can also be culturally and politically distasteful. The pills are little chunks of Western technology and culture, symbolizing an objectifying biomedical approach to human health and disease, and the pills are produced by multinational corporations in affluent Northern countries, some of them ex-colonizers. All in all, it can be a bit much to swallow.

In Tanzania this week, a news report states that quite a number of HIV-positive patients are going off their treatment and embracing traditional therapies. Some are dying in the process. Perhaps the time is ripe for the next phase: not HIV treatment, but HIV cure. No more pills, no more CD4 counts, no more going to the hospital and being ill-treated by staff. But who can say whether the cure would come without its own medical, cultural and political complications and dependencies.

Scale up and follow up: the struggle to stay on AIDS treatment in Africa

Not so long ago, the number of HIV-positive persons in Africa who had access to antiretroviral drugs was painfully low. Through important initiatives such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, millions have been put on AIDS treatment in the past few years. Available graphs on treatment access show a healthy upward trajectory, flatter in some parts of the developing world, and steeper in others, but nevertheless going up. And up is good.

A recent report in the New York Times shows another side of the story. Getting people started on antiretroviral drugs is one thing, keeping them on the treatment is another. HIV treatment, as it currently stands, is lifelong. Once you start, there is no stopping: or rather, there is stopping, but with disasterous consequences for the health of individuals and potentially for the community (if expensive to treat resistant strains of HIV thereby emerge). But keeping people -- increasingly vast numbers of them -- from defaulting on their treatment is a tremendous challenge with many obstacles. It is hard to know how many are 'lost to follow up', but if it is as the report states (between 15-40%), then we are talking about millions.

The agencies that are to be praised for efforts to increase treatment access may also shoulder some of the blame for the current situation. For years, 'numbers of persons on treatment' were the stuff of progress reports, the ultimate marker of program success, and where efforts and funding were to be largely concentrated. The focus was not on keeping people on their treatment regimes. If hell is not to be paved with good intentions, attention is going to have to subtly shift, the causes of loss to follow-up will have to be thoroughly explored, and support will have to provide to those tracing treatment defaulters and coaxing them to take their drugs.