
Huge study finds drugs stop HIV transmission - ahakki
https://www.theguardian.com/society/2019/may/02/end-to-aids-in-sight-as-huge-study-finds-drugs-stop-hiv-transmission
======
joshlittle
U=U is fantastic science; though it hasn’t been enough to totally remove the
stigma of HIV, even in San Francisco. I believe it comes from not enough
dissemination of information regarding the nonexistent risk of contracting HIV
from an undetectable partner.

I’m also concerned that by focusing on HIV as a manageable, chronic condition
- we discount the need for a cure.

A dystopian future possibility that’s come through my head is the cure is a
century away despite progress, and U=U doesn’t do enough to remove the stigma
faced today regardless how much the public is informed of the science.

I believe that a cure is required to truly remove the stigma of HIV.

I can scream “I am undetectable” from the rooftops and what that entails It’s
never going to matter to the people that find creative ways to cancel plans,
get out of dates, etc. when I disclose my status as HIV+ to them.

I’m at least thankful for the people that tell me it makes them uncomfortable
to consider kissing or any sexual contact - even with this knowledge. And even
with pre exposure prophylaxis / PrEP.

~~~
dillondoyle
My problem with this is how can I verify my hookup is taking their meds and
undetectable. Trust but verify doesn't seem to work here for hookups and one
night stands.

The amount of positive guys on PrEP or even non-positive guys on PrEP who
refuse condom sex seems to be greatly increasing. And it seems like there is
now discrimination the other way; can't tell you how many times I've been
pressured or refused or looked down upon for refusing non-condom sex or not
going on PrEP myself.

~~~
wan23
You can't be positive and on PrEP. The protocol requires testing every three
months, and in the very rare (so far cases number in the single digits)
situation where it fails, the patient is moved to a more appropriate regimen.

~~~
dillondoyle
also sorry just re-reading. i typo-ed: e.g. positive guys that are on
treatment (obviously not pre-exposure) and undetectable (which my point is I
can't verify)

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torstenvl
Through the '90s and even into the very early 21st century, doctors would hold
off before starting antiretrovirals. After acute HIV infection (which often
causes flu-like symptoms, known as sero-conversion sickness), the body
naturally suppresses the HIV infection to manageable levels. So the standard
advice was not to medicate yet.

Of course, that meant that most HIV-infected individuals were still
contagious. Their viral levels were low, but they weren't so low as to prevent
transmission.

Combined with a social stigma that kept people from getting tested, this
medical treatment philosophy is a major part of why HIV became as prevalent as
it did. I understand why - early drugs like AZT were even harder on the
patient's liver than modern drugs. But at best that seems myopic; at worst, it
was negligent from a public health perspective.

It is probably a bad thing that, at least in the U.S., we separate the medical
field from the public health field so arbitrarily. Maybe -- hopefully -- this
development in HIV treatment and the evolution of antibiotic-resistant
bacterial infections will make us rethink this dichotomy.

~~~
fucking_tragedy
> _I understand why - early drugs like AZT were even harder on the patient 's
> liver than modern drugs. But at best that seems myopic; at worst, it was
> negligent from a public health perspective._

Today we have drugs that prevent the initial infection of HIV, they're dubbed
pre-exposure prophylaxis drugs. The only drug approved for this use in the US
is a formulation called Truvada. It can cause bone and kidney damage, and is
contraindicated in patients with renal impairment. Gilead, the drug's
manufacturer, has risen the price of the drug from $6 to $1600 a month.

Other formulations, such as Descovy, have less of an impact on the renal
system. Gilead has been sued for allegedly withholding the drug in order to
time its introduction with the expiration of Truvada's patent in 2021[1].

Truvada's pricing, side-effects, and contraindications keep it from reaching
many of those who are at risk of becoming infected with and transmitting HIV.
Alleged patent timing is preventing the release of safer drugs that are just
as effective. While we've come very far, we still haven't escaped negligence
from a public health perspective.

[1] [https://www.marketwatch.com/press-release/mass-tort-
alleges-...](https://www.marketwatch.com/press-release/mass-tort-alleges-
gilead-sciences-inc-withheld-safer-drugs-from-hivaids-patients-manipulated-
patent-timing-for-profit-announces-jenner-law-2019-04-19)

~~~
MrEldritch
By "alleged patent timing", do you mean the _patents_ are only alleged, or
that the _expiration dates_ of those patents are only alleged?

Because either one of those statements is ... confusing to me.

~~~
fucking_tragedy
If you read the citation I gave in the OP, Gilead is alleged to have withheld
the introduction of Descovy for PrEP until their patent on Truvada expires.

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gravypod
Another amazing advancement that I didn't know much about until hearing of
from a friend are PrEP treatments. In terms that I understand it's a class of
drugs that can be used as a treatment for HIV that is prescribed to someone
who have not contracted HIV. By taking the drug you lower your chance of
contracting HIV on exposure.

"Studies have shown that PrEP reduces the risk of getting HIV from sex by more
than 90% when used consistently. Among people who inject drugs, PrEP reduces
the risk of getting HIV by more than 70% when used consistently." [0]

I found this site to be very interesting when reading up on the topic:
[https://prepfacts.org/prep/the-research/](https://prepfacts.org/prep/the-
research/)

[0] - "How well does PrEP work"
[https://www.cdc.gov/hiv/basics/prep.html](https://www.cdc.gov/hiv/basics/prep.html)

------
eecc
The HIV plague is wiping out the productive age group in Africa.

I sympathize for western patients and am glad the condition is treatable for
them... but we really should figure out how to deploy treatments to African
residents, implementing the logistics, delivering the education, removing the
graft and corruption that keeps killing hundreds of thousands.

~~~
krageon
We can do both. There is absolutely no reason why a breakthrough has to be
suffixed with "well that's great, but it would be much greater to look at this
demographic!". These are all people, and they all deserve treatment equally.

~~~
neuronic
You are right. So we must look at why this isn't happening. From a moral
perspective it should.

Resources and capability are available but the ones at the steering wheel are
not willing to allow them to be used. Otherwise it would be done, right?

Does anyone have any explanation for this? How popular would this action be
with the people of North America/Europe/Asia? Would it even make a dent in
terms of budget when compared to typical foreign aid payments for example?

The Chinese are heavily investing in Africa to gain influence and resources,
the Europeans ship off billions of Euros in goods and cash for aid, the US is
also buying influence with aid all over Africa.

Is it simply not paying off? There is no short term political or economic
benefit here? Is that it?

~~~
cblades
>Resources and capability are available

I think that's something you have to support. Certainly it is _possible_ , but
what else are you putting off or de-prioritizing to do it?

I certainly agree that we should aim to make the most impactful improvements
in the most people's lives, I just don't quite know how a global society or
even individual countries go about a reasonable prioritization process.

------
bichiliad
It seems like a really scary gamble to have unprotected sex with someone who
is HIV-positive for a research study, and I was wondering how the study found
such couples. The paper mentions that they identified couples with one HIV-
positive partner, and then followed up with them to see if they reported
condomless sex.

~~~
mattkrause
Randomizing people to have sex with an HIV+ or placebo partner would bring
down the IRB's wrath _quite_ quickly. For that reason, a lot of this stuff is
done observationally, where you just track people doing whatever they were
going to do anyway. The data is often not as clean as a randomized controlled
trial, but it seems much more ethical.

An earlier trial (HPTN 052) did actually run a RCT, but the treatment strategy
was randomized, not the partner. It worked so well that the trial was actually
stopped early and everyone was offered antivirals. Cohen et al. (2011)
reported the results here:
[https://www.nejm.org/doi/10.1056/NEJMoa1105243?url_ver=Z39.8...](https://www.nejm.org/doi/10.1056/NEJMoa1105243?url_ver=Z39.88-2003)

~~~
Fomite
You can get near to an RCT with newer trial designs like stepped-wedge
designs, which are _way_ better in terms of equipoise and nearly as efficient
statistically.

~~~
mattkrause
Those are still interventional though, right?

(I probably should have written observational vs. interventional instead of
obs. vs RCT).

~~~
Fomite
Yep. The stepped-wedge design, for example, is one where everyone will get the
intervention, but the time in which they get it is randomized.

------
Circuits
Wait a second, so 15 men who were participating in an HIV study with their
partners managed to contract HIV from someone else, during the study, who
wasn't their partner??? ?

~~~
mikelyons
What about that is "?" x4 surprising to you?

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jl6
Just thinking theoretically... if 100% of HIV positive individuals became
untransmitters, would HIV die out with that generation?

~~~
orcasauce
Consider what we did to smallpox. It's gone, but not really.

~~~
boyband6666
Also the headline is massively misleading - almost immediately they point out
that many people don't know their status.

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thefounder
What "fully suppressed" means and for how long? I don't think many would risk
if were told their (potential)partner was tested at the beginning of the month
and the virus seamed "fully suppressed". Why take the risk?

~~~
mdhen
It means undetectable, so the hiv rna test has a lower limit. Say 12 copies
per ml. Undetectable means it is below the level.

You'd normally want to be UD for 3 months before engaging in unprotected sex
with your informed partner.

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sAbakumoff
in mice?
[https://twitter.com/justsaysinmice](https://twitter.com/justsaysinmice)

