Pre-Exposure Prophylaxis or PrEP

Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. This blog looks at some of the pros and cons of PrEP.

Friday, January 28, 2011

Mixed Messages From CDC for Men Who Have Sex with Men

Apparently only 'high-risk' men who have sex with men should use Truvada as pre-exposure prophylaxis. Who are these high-risk men but those who tend not to take precautions? PrEP, if it works, is a precaution. Therefore, the only people likely to take PrEP as recommended would be considered to be low-risk.

But is Truvada really intended for those men who have sex with men who are at highest risk of HIV infection? I don't really believe that. I would suggest that Gilead, the manufacturers of Truvada, intend to break into the recreational drug market. I'd say they want people who don't wish to use condoms to use PrEP instead. I think that's what the whole pharmaceutical industry wants.

The US Center for Disease Control (CDC) has not approved the drug for preventive use. Yet they issue guidelines for its use as PrEP. Anyone can use Truvada if they can get hold of it and any doctor can prescribe it. I think we can be fairly certain that it will be prescribed and used as PrEP, as a recreational drug.

After all, people who are at high-risk of becoming infected, well, take risks. CDC not approving it as PrEP, but issuing guidelines, is not going to make people think twice. And whether Truvada results in "78% fewer cases of HIV infection" or reduces "infection by 44%" will make little difference to those who may already be engaging in have unprotected anal sex.

CDC and others are giving mixed messages and they seem to be doing so knowingly. If people listened to advice, they wouldn't be at high risk of being infected with HIV. Therefore, I suspect this whole scenario is calculated to maximize profits and minimize risk for the pharmaceutical industry and has little to do with the risk of contracting or transmitting HIV.


Friday, January 21, 2011

Crumbling, Staffless African Health Systems Bombarded With Drugs

With all the hubris about drugs and new medical technologies, you'd think that hospitals in East African countries are ready to save their whole populations if they could just get hold of the latest drugs. This is far from the truth.

Drugs that arrive in the country often don't get distributed and expire before they are used, they get distributed to the wrong people and disappear into the black economy, they are prescribed by people who don't know how to prescribe them properly, they are already useless because of widespread resistance, etc.

Even antiretroviral drugs have a bit of a mysterious time once they reach here. Some people are kept alive by them but the majority of people who need them don't yet get them. Another mystery is how many people die while on the treatment, or why treatment sometimes fails where it would have been predicted to succeed. And a huge number of infants are still infected by their mothers, despite promises that this phenomenon will soon be phased out.

Despite all the money being thrown at HIV, and very little else, health services just can't cope. There isn't the infrastructure or the level of skill required to ensure the health of most people and many, even those with HIV, are dying of easy to treat illnesses.

It's good to see an admission that the problem is at least partly with health systems but it would be even more comforting to hear that big funders are doing more to improve health systems than just talking about it. Strategies like PrEP, treatment as prevention, mocrobicides, etc, will be of little use if they don't get to people or if they are not used optimally when they do.

Which reminds me, why do countries that are so short of infrastructure, medical supplies and especially personnel think that mass male circumcision is so important when their health services are in crisis and have been for some time?

Apparently Tanzania has circumcised a few thousand men but so have Uganda and other countries. And Kenya claims to have circumcised 250,000 in a very short space of time. I'm glad I'm not one of the, having seen the state of some health facilities in East Africa.


Tuesday, January 4, 2011

Science Awards: Virtuous Circle or Spooky Cabal?

There are few things that make me think 'collusion of interested parties' than prominent awards, with the exception of peer reviewers, who always me think of Freemasons for some reason. For all I know, though, they could all be completely innocent and/or unrelated.

Anyhow, Science Magazine has awarded two of their ten prizes to the highly controversial and unconvincing Tenofovir vaginal gel (the CAPRISA 004 trial) and the almost equally unconvincing pre-exposure prophylaxis drug (the iPrEx trial). There is a lot of USAID and PEPFAR funding behind both of these, so the poor trial results may not matter too much.

The ongoing concentration on capital hungry technologies and technical expertise tends to mask one of the biggest problems that poor countries face: shortage of skilled health personnel. Here in Tanzania there is one doctor for approximately every 50,000 people (compared to about one for every 170 people in Cuba). What are people going to do with all these drugs and other technologies, assuming they can ever afford them?

This problem, like many of the other real problems developing countries face, is ignored by the cabals of industrialists, megaphilanthropists, technologists, politicians, religious fanatics and other jackals of the HIV industry. But it is not going to just go away.

Of course, it's of little interest to the same interested parties, who wish to establish markets, not undercut the very source of their current and future wealth. In addition, HIV related technologies need to be put through rigorous trials in countries with high HIV prevalence to prove their worth. So even if 'aid' money will not be diverted to subsidize these markets, contacts with developing countries need to be maintained. After all, that's what 'aid' is, a tool of foreign policy.

Botswana has announced that it is going to concentrate on prevention, and not before time. The country has one of the worst epidemics in the world. But perhaps now they will reject the self-serving arguments about treatment 'being' prevention and about HIV funding 'strengthening health systems' or about it  not diverting funding from other health issues. If only other high prevalence countries, and even low and medium prevalence countries, would follow suit and stand up to the moneyed interests.

Botswana simply can't afford antiretroviral drugs at current levels of usage, never mind the annual increases in incidence adding to the costs, along with resistance and other factors ensuring that costs will rise exponentially, not linearly, in the future. All high prevalence countries with large numbers of people on antiretroviral drugs are experiencing the same problems as Botswana.

But Botswana also seems to have realized that much of the money spent on behavioral interventions has been wasted. Perhaps they'll take another step and realize that this failure of behavioral interventions may be because HIV transmission is not all about sexual transmission?

Using mere technologies to solve deeply rooted development problems is as likely to work as planting seeds on the moon (in its present state). And if I thought the HIV industry really wanted to solve development problems, health and HIV related problems in particular, I would think they are behaving like fools.

But I don't think anyone seriously believes such naive claptrap. They are business people, involved in protecting their markets and ensuring that they make as much money as possible, regardless of the consequences for people in developing countries.