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.
It's a lot to ask of someone - on both sides. How do you think someone could approach this in a way that preserves your humanity and your privacy?
It's not exactly the same, but it's not entirely different.
Even with testing, not all STD's show up on tests - this is why folks get tested regularly. Many folks won't know they have an STD (think HPV). Condoms break, get forgotten, and so on. People do stuff when they are drunk.
Rape happens (rape isn't a lack of trust but rather something else entirely).
These aren't indicators
of lack of trust
- Your partner that they don't lie about taking contraception, that they have taken it as required.
- The medical sciences and medical regulatory authorities that the contraception works as expected.
- Pharmacist that they don't sell counterfeit medicine
and many others. Society is largely based on trust.
Humans happen and make mistakes. Condoms break. Therefore, plan B.
One doesn't have to be promiscuous or untrustworthy to have an STD. All that means is that you've had sex with someone. Someone might not even know they have an STD either. Even if folks have more than one partner, it doesn't actually mean they are sleeping around or that they are being dishonest, nor does it mean they'll get an STD.
In addition, if you are trusting that your partner has taken something as required, you probably are in a sexual relationship with someone you are familiar with. Otherwise, the prudent thing would be to use a condom and hope it does not break.
Contraception working as expected leaves a lot of room for error. Again, condoms break. Medications interfere with hormonal birth control and most folks don't take it like laboratory settings, which increases risk of pregnancy. This is all still "working as expected".
Note also that in interactions with humans, we generally don't have a precise probabilities.
I'm using contraception method X
On a more practical level, I would probably go on PreP if I regularly had hookups with men. I’m actually somewhat envious of the gay scene in that regard. The option just doesn’t meaningfully exist at the mostly-hetero sex parties I’ve been at.
I mean I'd worry that they were being honest, but mistaken. I'd have to do a lot of research on the efficacy and frequency of testing beforehand (e.g. it's possible that it might be calibrated to be frequent enough to provide proper care for the patient, but not to guarantee to protect partners).
So really you need to be trusting that they are responsible enough to take their drugs every day. These days that is pretty easy, most people take 1 pill in the morning and that's it.
The fact that people don't trust it means nobody's casually taking it or taking for granted that other people are taking it. So it increases awareness of the potential for contracting HIV and underlines the need for protection. At the same time, you can independently choose to take it and provide yourself more protection. So I think it all balances out.
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.
>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.
Seems like a great social signal that those aren't people you need to bother with having in your life.
It is simple. Do not have hookups with HIV+ people. Why are we normalizing this.
I wouldn't have a problem being in a relationship with someone with HIV, but even if his viral load is undetectable, I would still insist on protection for high risk activities.
And of course, that might mean an actual cure is detrimental to the bottom line, which might impact funding for any of these studies.
This also assumes that the only motivation is money, if a researcher came up with a cure for HIV they would become an instantaneous scientific god, immortalised in writing, films, having streets and libraries named after them. They would be a hero. That motivation is pretty powerful for many (not for all of those things, but the be a hero part).
A subset of the population will become resistant to certain classes of drugs, because people do stop taking drugs etc. And gain resistance, then pass that on, but for a specific individual their current regimen should be good for as long as they take it. Realistically people change drugs every so often as better drugs with lies side effects are released, but not because of new resistance development.
Now this did used to be a bit if an issue since people had to take multiple pills at different times a day. Having to do that makes missing doses easier, and then resistance can develop. But these days most people are on a single pill taken once a day that completely eliminates that risk.
You're thinking of this like antibiotics, when it's really not a comparable situation.
Drugs like this, and HIV as a manageable, chronic condition have the potential to vastly change the face of the HIV epidemic.
A bigger concern, in my opinion, is how you get the drugs necessary for this to a place like Uganda, where the per-capita annual health budget is $0.05.
Ugandan here, didn't know this! Or hadn't calculated. But the public health system is really terrible. It's unbelievable. However, ARVs are quite available, I know people that have no trouble getting them for free.
Like a vaccine-preventable disease near elimination, I worry a lot about people taking their foot off the gas.
And last I talked to HIV control folks in Uganda (several years ago, admittedly) there was a lot of concern about survivability meaning a dramatic increase in the prevalence of HIV, and thus the demand for ARVs.
That surely must be a typo, right?
Malaria, HIV, myriad diarrheal diseases, vaccines.
You've got a nickel per person.
It says $15 per capita.
It seems hard to get a fixed number. Doing math off the Uganda MOH budget puts it at about $4.
But it should also be noted that even the optimistic figure likely also includes things like hospital construction, money to pay healthcare workers, labs (and lab reagents), etc. that isn't what people normally think of.
I'd really like my number to be wrong though. Because even $15 per person is...dire.
Your reasoning also leaves out that a lot of health care never goes through government coffers, both in African nations but also, for example, in the US.
For that matter, if you'd like me to talk about the way non-African healthcare systems are broken, I'm happy to do that as well, that just happens to not be what this thread is about.
Also, the programs we are talking about rarely go through non-governmental sources.
Literally expired last night. How frustrating.
Sadly, missed by the Internet Archive.
potentially decades away
The virus also stay dormant within your cells, and it is not absolutely clear where, yet. Other viruses which do this (chickenpox, herpes, papillomavirus, ...) are not cleared from the body by the immune system either, but at least the immune system can control them as long as it is healthy enough.
This facts, of course, are no reason to be pessimistic about a cure/vaccine, just explains why it is taking that long. A cure might also pad the way to cure other diseases such as chickenpox and herpes, which may lead to complications later in life.
Generally, it's much easier to develop a vaccine for more stable viruses.
We might be able to target some sort of antigen on the virus that's highly conserved even with that mutation rate, but that's a big if.
We have antibiotics primarily from fungi derived substances, but there are no other class of substances we’ve been able to appropriate for our own use to treat viruses.
I find it amazing that viruses, which are supposedly “simpler” aren’t more vulnerable.
But thinking about it, prions are even simpler and have no know treatments.
This demonstrates, then, that complex systems can be quite fragile.
That's WHY they're less vulnerable. Less complexity reduces the attack surface. With microbes, there are lots of ways to disrupt their biological processes, but viruses have fewer attack vectors, making it difficult to target them.
Acyclovir definitely seemed to help when i had chickenpox!
"It can treat herpes virus infections, including shingles and genital herpes. It can also treat chickenpox. This medication does not cure herpes, but may prevent herpes sores or blisters."
How come that not wanting to risk getting STDs or HIV infection is considered a negative thing?
If we can effectively make HIV non-transmissible then it shouldn't take very long to wipe the virus out (or at least come very close) and the stigma will no longer apply.
The cure seems to be decades in the future though, so I don't really see an alternative to pushing for both.
That is, an individual that is "undetectable" (formerly HIV+ but underwent treatment so that the viral load is not detectable) is still viewed as a potential source of HIV transmission, despite assurances from the medical community that an undetectable load is unlikely to be a source of transmission.
Is it wrong for potential partners to want to know if someone carries any sexually transmitted virus (HIV or otherwise)?
Is this basically just saying trust the opinion of the current medical establishment?
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.
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.
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.
Your premise is correct, that the elevated price is harming the cause of fighting HIV. Your cost figures are incorrect however.
In Canada, even their health system has approved generic Truvada at wholesale for $400 per month (Truvada is twice that in Canada). Your $6 figure is plain wrong. That's the lowest wholesale cost anywhere in the developed world at any point in the drug's history. That's not the cost that it started out at in the US. It was about $1,150 (average reimbursement rate) in 2009. Truvada brought in $567 million in sales in just 2005 alone, they didn't accomplish that at $6 per month in the US. Gilead further increased the wholesale price by 45% over six years, from 2012 to 2018.
Because either one of those statements is ... confusing to me.
"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." 
I found this site to be very interesting when reading up on the topic: https://prepfacts.org/prep/the-research/
 - "How well does PrEP work" https://www.cdc.gov/hiv/basics/prep.html
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.
As other commenters wrote, the huge challenge that lays ahead of us is to take this progress to the African continent; the road ahead is just as hard as the one that has brought us here
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?
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.
Absolutely true, but rarely are there enough resources to treat all patients simultaneously, hence triage. If the death rate in one group is higher and faster than another, you should focus on that group first, generally.
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...
(I probably should have written observational vs. interventional instead of obs. vs RCT).
Not sure if that's the part you're having a hard time with or not.
You'd normally want to be UD for 3 months before engaging in unprotected sex with your informed partner.
People have differing ideas about what acceptable and unacceptable behavior is. If we required that taxes only be collected for the set of behaviors everyone agreed on, we'd have no taxes, and no government.
Even if we agreed that promiscuous people should not receive public medical treatment (which is not a position I hold), would you suggest condemning people who contracted this through no act of their own as well?
Parents can give it to their children, and there are nonsexual ways you can end up with bodily fluid transmission.
Assuming you're describing the book I think you are, there are a number of editions of said book in which one of the protagonists shows mercy toward the sick and ostracized people.
I dislike the idea of refusing treatment for some based on certain criteria for a number of reasons - one of the big ones is that I've witnessed the enormous irrational engine that is medical insurance billing in the US, and I don't really trust ~anyone to decide on whether a treatment should be paid for when they have a fiscal incentive one way or the other.
I'm trying to understand what you're specifically objecting to - it's not researching treatments for these conditions being funded publicly, I think, just giving them to people who were affected by risky behaviors?
I wouldn’t phrase it in the passive voice, but yes I don’t object to research or people spending their own money on the consequences of their own behavior.
And we do that because it's a reasonable thing to do overall. And definitely cheaper than trying to figure out who's fault each health issue was. You got a heart attack? Why didn't you cycle to work? How much processed food did you eat? Are you sure it's not your fault?
What about exercise - You got injured while running? You didn't have to run, that was your decision. You got hit by a car? Why did you leave the house; your decision again.
A public, shared coverage has to ignore responsibility to some extent. Or we'll end up with system where you need too prove every time you're not too blame. I think that would be immoral - even according to a book you mention.
No, but these cases can be identified. For ex - children or people with unfaithful spouses. A majority of HIV infections are due to unprotected sex.
> there are nonsexual ways you can end up with bodily fluid transmission.
Please do tell use about these nonsexual ways. Cause I was under impression that normal contact during daily life carries no risk.
Sharing syringes (e.g between drug users).