Saturday, March 29, 2008

When Good News Makes for Tough Choices

I know, it's been a while. But at least I brought a new look for spring!

One of the reasons I've been away from blogging has been that my volunteering for the local AIDS center has kept me busier than usual. Other than looming budget cuts we had to deal with a bit of potentially very good news for millions of people living with HIV.

EKAF, the Swiss National AIDS Commission published a report in the Schweizerische Ärztezeitung (Swiss Journal for Medical Professionals) stating that research shows that HIV positive patients whose viral load has been undetectable for more than 6 months as a result of the usual combination therapy no longer seem to be passing on the virus to their sex partners (if they are free of other STDs). You can read an unofficial translation of the article here.

To clarify things for those not overly familiar with the subject matter: The combination therapy is not a cure. Once you go off the meds, the virus comes back with a vengeance.

I am still not quite sure how I feel about that publication. On the one hand, I have friends whose partners are HIV-positive while they are not, and this must be a huge relief for each half of those relationships. Heck, most people with HIV would have a burden lifted from them.

On the other hand, I have quite a few questions.

First of all, the research seems to be mostly based on heterosexual intercourse. As anal sex has long been known to be the riskiest for transmission,how sure are we that the results can be translated to the gay population?

Secondly, a doctor working at the local Chronic Infectious Diseases clinic told me a couple of years ago that almost all new infections they see are with virus strains that already have a level of immunity against some of the drugs being used in combination therapy. That means that at some point in the chain of infections, this virus was transmitted by a person who had received anti retroviral medication for quite some time. Are we to believe that all those people showed bad compliance with their medication regimens to remain infectious? And wouldn't infection rates actually go down instead of up as they have in recent years?

And finally: How do we prevent these news from filtering down to "Condoms aren't necessary anymore" in too many heads?

I'd like to see more research into this. As usual, we should avoid the easy answers. Neither going on with the same old prevention message nor calling off the dogs is in any way advisable here. If the results from the Swiss study prove accurate, we need to get more people tested and get infected people on medications sooner. We need to fight even stronger to get those with HIV in developing countries access to medication as it would not only add years to their lives and life to their years, it would actually slow down the spread of the disease.

As for all of us individually, I'd listen to this advice that the late Mary Wells is dishing out in one of my favorite songs by her:

3 comments:

James Figueiredo said...

Howdy, Chris!

Whoa, this is QUITE a change in look for your blog - I like it! Hope you can post more often, too!

And I get what you're saying - Lots of times, any news concerning improvement on HIV therapy or medication is seen by too many people as "just as good as a cure, so let's get wild".

Hugs,
J.

Pedro said...

I have to say that I share your caution and general worry about this news Chris. It seems to me that the announcement was more leaning towards glorifying researchers than unbiased reporting of data. I haven’t really read the article but from what you told me even if the researchers had the most purest of intension, such an announcement is certainly a double edged sword. This is especially true considering that we are currently experiencing a new flare in infections world wide as the newer generations becomes less and less cautious and they are forget the lessons of our past.

Like I said, I haven’t read the article so I can’t comment on the research model they used or evaluate the date behind the claim. I can comment that undetectable viral loads have already been linked to reduced transmission rates. The question here is if this project followed individuals who actively used other forms of protection i.e. condoms. I highly doubt they solely followed couples that completely practiced unsafe intercourse without implementing some form of barrier method for protection, that would be completely unethical even for the Swiss… They are all gypsies I say. If they were using condoms during intercourse they can not claim that undetectable viral loads alone can prevent transmission.

Anyhoo, one also has to take into account the population size of the individuals and the amount of sexual encounters. These numbers need to be substantially high if one is to claim that the result is significant. Considering HIV transmission from unprotected intercourse is actually very small, Hepatitis C viral transmission is much much higher, you need a larger population size to prove the results. The explanation here can get really confusing and long winded but lets consider this. Lets say they followed 10 couples for 5 years who on average had 48 sexual encounters a year. Now if you also take into account that the risk of transmission in heterosexual is less than one percent per encounter… It’s perfectly reasonable that no transmission would happen in 5 yrs just by factoring int chance by considering the over-all low incident rate.

Now if want to really prove that undetectable viral loads prevent infections then you’ll have to have a study with approx 5,000 couples having unprotected sex more than once a week, (if they are gay couples, the risk of transmission per encounter is higher and they also certainly have sex more than once a week) and they get NO transmission in that period of 5 yrs. This would cause the scientific community to have a collective “YAY!!!” and cream their pants.

But the majority of the world does not have a scientific background to reasonably see these faults. Even more individuals still pay attention only to the headline “undetectable viral loads prevents transmission” or to the media headline that would probably go something like “HIV drugs can now prevent the spread of AIDS during sex” . I agree that this is a dangerous message indeed Chris. CHILLS. This reconfirms my earlier comment that the Swiss are dirty dirty people and are just a bunch of gypsies..

-Pedro
PS I just wanted to also say that undetectable viral loads in the blood does not mean undetectable viral loads in other fluids like semen. Many body cavities prevent proper distribution of drugs. The Blood-Testie barrier itself causes low therapeutic levels of drugs in the testies, which would then result in higher levels of virus in semen than blood. Just a random fact for you all

PSS
I really don’t believe the Swiss are dirty or gypsies. Lets be honest they tend to be uber hot.

Pedro said...

I have to say that I share your caution and general worry about this news Chris. It seems to me that the announcement was more leaning towards glorifying researchers than unbiased reporting of data. I haven’t really read the article but from what you told me even if the researchers had the most purest of intension, such an announcement is certainly a double edged sword. This is especially true considering that we are currently experiencing a new flare in infections world wide as the newer generations becomes less and less cautious and they are forget the lessons of our past.

Like I said, I haven’t read the article so I can’t comment on the research model they used or evaluate the date behind the claim. I can comment that undetectable viral loads have already been linked to reduced transmission rates. The question here is if this project followed individuals who actively used other forms of protection i.e. condoms. I highly doubt they solely followed couples that completely practiced unsafe intercourse without implementing some form of barrier method for protection, that would be completely unethical even for the Swiss… They are all gypsies I say. If they were using condoms during intercourse they can not claim that undetectable viral loads alone can prevent transmission.

Anyhoo, one also has to take into account the population size of the individuals and the amount of sexual encounters. These numbers need to be substantially high if one is to claim that the result is significant. Considering HIV transmission from unprotected intercourse is actually very small, Hepatitis C viral transmission is much much higher, you need a larger population size to prove the results. The explanation here can get really confusing and long winded but lets consider this. Lets say they followed 10 couples for 5 years who on average had 48 sexual encounters a year. Now if you also take into account that the risk of transmission in heterosexual is less than one percent per encounter… It’s perfectly reasonable that no transmission would happen in 5 yrs just by factoring int chance by considering the over-all low incident rate.

Now if want to really prove that undetectable viral loads prevent infections then you’ll have to have a study with approx 5,000 couples having unprotected sex more than once a week, (if they are gay couples, the risk of transmission per encounter is higher and they also certainly have sex more than once a week) and they get NO transmission in that period of 5 yrs. This would cause the scientific community to have a collective “YAY!!!” and cream their pants.

But the majority of the world does not have a scientific background to reasonably see these faults. Even more individuals still pay attention only to the headline “undetectable viral loads prevents transmission” or to the media headline that would probably go something like “HIV drugs can now prevent the spread of AIDS during sex” . I agree that this is a dangerous message indeed Chris. CHILLS. This reconfirms my earlier comment that the Swiss are dirty dirty people and are just a bunch of gypsies..

-Pedro
PS I just wanted to also say that undetectable viral loads in the blood does not mean undetectable viral loads in other fluids like semen. Many body cavities prevent proper distribution of drugs. The Blood-Testie barrier itself causes low therapeutic levels of drugs in the testies, which would then result in higher levels of virus in semen than blood. Just a random fact for you all

PSS
I really don’t believe the Swiss are dirty or gypsies. Lets be honest they tend to be uber hot.