Recently, the international media was flooded with reports of a baby in Mississippi who was cured of HIV. The miraculous procedure was performed by Dr. Gray, a pediatrician with the University of Massachusetts alongside Dr. Persaud of John Hopkins University. The daring move to treat the child was done thirty hours after the child’s birth, even before getting confirmatory test results of infection. In addition, Dr. Gray went a step further to use three drugs instead of the usual one. This could have posed a health risk, but against all odds the child survived and even after 30 months was found to have no viral load despite her antiretroviral therapy being discontinued at 18 months as reported by the mother.
The one question on everyone’s mind was: Could this be the breakthrough in finding the cure to HIV/AIDS epidemic? We would all like to think so, but the fact still remains that there are over 35 million people living with HIV globally and 1.6 million fatalities annually. In Kenya, there are 1.6 million people living with HIV and with such figures, the main focus currently is not to find a cure but to prevent transmission of HIV.
Several trials have been launched over the past few years to investigate whether certain drugs could be used to curb HIV infection before exposure. One such study funded by the Bill and Melinda Gates Foundation was started in Kenya in 2011. As it was to prevent (prophylaxis) transmission before one was exposed to HIV it was named Pre-Exposure prophylaxis (PrEP). The study used two drugs to find out if there is a decrease in HIV transmission in cases where one partner is positive and the other is not. The HIV negative partner was enrolled in the study and placed under one of the two drugs with some being given a placebo, though they were later reassigned to the active drug. There was a 63% reduction of HIV transmission with Tenofovir and 75% with Truvada in comparison to the placebo.
Another study known as VOICE (Vaginal and Oral Intervention to Control the Epidemic) study, whose results were released on 4th March 2013 proved that the battle was far from over. The results of this large scale study among African women indicated that none of the three pre-exposure prophylaxis and microbicide interventions-- daily oral tenofovir, daily oral TDF/FTC (Truvada), and daily 1% vaginal tenofovir gel-- provided additional protection against HIV in the study. However, the disappointing results were more likely as a result of the large number of women who did not use the products as directed and not due to the inefficiency of the drugs themselves.
“The VOICE results reinforce what we already know from previous trials: these interventions work when they are used, and they don’t work when they are not used,” said Mitchell Warren, AVAC (AIDS Vaccine Advocacy Coalition) Executive Director. “PrEP is still a valuable option for many women and men, who recognize their risk and can take PrEP consistently. Now we have a dual responsibility to understand who might benefit from daily PrEP and ensure that they can access it, and to accelerate the development of additional options that can meet the urgent needs of others.”
For the drugs to work they have to be taken as indicated. It is paramount that the patients take the full dose as HIV will not just ‘disappear’. This raises an important question: What can be done to encourage people to take the drugs as directed or even to take the medication in the first place?
In Partners of PrEP study performed in Kenya, some people cited the ‘pill burden’ to be one of the reasons for lack of adherence. Others were afraid of the stigma associated with HIV and therefore to avoid people thinking that they were infected even when they were not, they would not take the drugs, or at least not every day. This defeated the whole purpose of the drugs to prevent transmission before one is exposed to the virus. Therefore there is need to package the drugs in such a way that the recipients adhere to treatment by comfortably using them, and in doing so decrease the rate of HIV transmission.
AVAC (Global Advocacy for HIV prevention) calls for accelerated research and development of additional HIV prevention options that rely less on adherence making it easier and more desirable for use, such as long-acting rings and injections and less stringent dosing schedules. The call by AVAC is echoed the world over, stemming from the WHO report showing that there are over 2.3 million new HIV infections annually.
Moreover HIV-TB co-infections need to be tackled firmly to reduce TB related deaths among people living with HIV. In 2012, people living with HIV accounted for 1.1 million (13%) of the estimated 8.7 million people globally who developed TB. While antiretroviral therapy reduces the risk that a person living with HIV will develop TB, among the 10 reporting countries with the largest number of HIV/TB cases on antiretroviral therapy, only Kenya and Malawi were delivering antiretroviral therapy in 2012 to more than 50% of estimated incident HIV positive TB cases. Despite the fact that over 600,000 people are on anti retrovirals in Kenya, a large coverage gap of approximately 30% still remains.
According to Dr Anthony Harries, Senior Advisor, International Union Against Tuberculosis and Lung Disease (The Union), “HIV-associated tuberculosis can be controlled by better scale up and implementation of tools that are currently available. We need to get more HIV-infected people earlier on to antiretroviral therapy as this is a most important way of preventing TB. In the high HIV-TB burden areas, the TB preventive effects of antiretroviral therapy can be further increased by the addition of isoniazid preventive therapy. We need to test all patients with tuberculosis for HIV, and those who are HIV-positive need to start antiretroviral therapy and cotrimoxazole preventive therapy as soon as possible."
Yes, we want to rid ourselves of this epidemic but we are still far from attaining control whether in terms of antiretroviral or adherence to pre exposure prophylaxis medication or dealing with co-infections and co-morbidities associated with HIV. As the search continues for more desirable and practical prevention methods and hopes for a cure are re-ignited, we are left with anti- retroviral therapy as our defense against the fatal consequences of this epidemic.
Diana Esther Wangari, Citizen News Service - CNS
November 2013
