So this is it. The twentieth anniversary of World AIDS Day, first established in 1988 at the World Summit of Ministers of Health on Programmes for AIDS Prevention. And as we look back at these past 20 years, one has reasonably to ask if it we’ve come to a time when we can, in fact, both celebrate our successes while remain ever-vigilant to the challenges ahead?
And I think for the first time we can. For unlike any time in the history of HIV/AIDS, we’re starting to see more than just a faint glimmer of hope. We’re seeing a shifting reality, with advances in medical science, public awareness, and even government policies that have been no less than unprecedented. That’s not to say we can all give a big sigh of relief. It just means, perhaps, that we can stop holding our breaths in the ways that we have.
Bottom line, the HIV/AIDS statistics remain as shocking as ever, with more than 33 million people infected worldwide and approximately 2 million killed each year through HIV-related illness. Three-quarters of these deaths occur in sub-Saharan Africa alone, with South Africa claiming more than the lion’s share.
So where is there hope? Where are the good, the bad, and the ugly? And what are the events in 2008 that should give rise to optimism, and which should give us more than a moment’s pause?
To answer these questions, here is a list, in my opinion, of the seven most important events in 2008 (in reverse order):
7. BETTER TREATMENT STRATEGIES FOR LIPODYSTROPHY
As we learn more about the efficacy of antiretroviral (ARV) therapies, so too are we increasingly faced with the often profound side effects that accompany treatment. Chief among these is lipodystrophy, the sometimes-disfiguring redistribution of body fat from the limbs, face, and buttocks to the stomch, breasts and back of the neck (accompanied by raise cholesterol levels and so-called visceral, “internal” fats).
What we do know is that all currently available ARVs have some propensity toward this, but the rise of newer drugs and better drug strategies have greatly reduced its incidence worldwide.
The bad news, however, is that the ARV most associated with lipodystrophy is one still widely used here, mainly in the public sector but also in parts of the private sector. Stavudine (also known as d4T and Zerit) has long been sidelined as first-line therapy in most parts of the developed world, not only because of lipodystrophy but other major side effects. But the message still hasn’t caught on here, mainly because the drug is so cheap and governments like ours often choose to “manage” the side effect rather than change to more expensive alternatives.
But here’s what we do know: with ARVs currently available in South Africa, we can, in fact, prevent or at least reduce the risk of ARV-related lipodystrophy. In a published study from the AIDS Clinical Trials Group (ACTG), we now know that Kaletra, a protease inhibitor class drug once thought to have a high risk for lipodystrophy, actually has a lower risk than many other ARVs. In fact, Kaletra has been shown to be a far better alternative to even Stocrin, a drug once thought to have minimal impact. And when pair with Truvada, the risk of lipodystrophy become next to nil.
The other bad guys? Stavudine and AZT when paired with Stocrin have dismally poor results, changing the very nature of how we view and treat ARV-related lipodystrophy.
6. CRYSTAL METH ABUSE ON THE RISE
To some, this is old new. Yes, crystal methamphetamine abuse in still on the rise, although we’re now only just beginning to understand how difficult a habit it is to kick, particularly as more-and-more of within own community have taken up “slamming” (or injecting) meth for the hypersexual high one can achieve.
What is even more dismaying, however, is research associating crystal meth use with the higher rates of treatment failure. In a 2008 study by David Cooper of the University of New South Wales, we learned that intravenous drug users (IDUs) actually have a 30% lower life expectancy rate than an HIV-positive non-drug user. And on top of that, in the U.S. and Europe we’re starting to see evidence that crystal meth use is associated with higher rates of drug resistance, as well as the increased risk of passing drug-resistant strains between IDUs.
So the question is, do we wait until the same thing happens on these shores? Or has it, in fact, already happened?
5. PEOPLE STILL GETTING TESTED TOO LATE
In a study published in Switzerland in 2008, researchers compared life expectancy rates between a cohort of newly infected patients in Switzerland with a similar cohort in South Africa. What we learned was that patients in South Africa actually have a better rate of drug adherence than their Swiss counterparts. So why then did they have a nearly 400% greater risk of dying in the first two years?
The answer is simple: we start treatment far too late here. Aside from the fact that many still only get tested after a major infection occurs, we also know that the current government protocols in-and-of-themselves contribute to this horrifying statistic. By starting ARV therapy with a CD4 count of 200 or lower (where many opportunistic infections are likely to occur), the government has knowingly put its citizens at greater risk for illness and death. We’ve known this for years, but still nothing has changed. In the private sector, treatment is now started with a CD4 count at or around 350, while in the U.S. and Europe, many are starting at or around a CD4 count of 500.
So why, you ask, doesn’t South Africa change? With nurses being the primary mechanism by which government ARV programmes operate, to re-educate tens of thousands of nurses – who have been force-fed the mantra, “200, 200, 200!” – is not only daunting but structurally problematic, forcing already overrun facilities to enroll 50-100% more patients with limited staff, supplies, and structures.
So do we give up then? What truly needs to be done if we are to ever turn around the pandemic in South Africa? This, alas, may be the greatest question confronting our newly elected government in 2009, as well as that of an international community faced with a financial meltdown that may far overshadow the crisis here.
4. FAILURE OF VACCINE TRIALS
So what can be said for finding “the cure” in 2009? Simple. It ain’t going to happen. Not this year. Not in the next ten.
That’s not to say twe won’t find a vaccine someday. It’s just means that we’ve got to stop fooling ourselves, repeatedly following the same needle-in-the-haystack approach that has failed us time and time again.
The most recent Merck vaccine trilas – using a so-called “adenovirus” associated the common cold – not only failed in testing, but ended up actually increasing the risk of transmission. And in the aftermath, many have called for a termination of vaccine trial and a redistribution of funding toward prevention and treatment programmes that have been proven to work
But does that truly mean that the hunt for the vaccine should be halted altogether? And where, in fact, do we go now that most of the vaccine trials have either been halted or stopped altogether?
What we did learn from the Merck trial was that a subset of those who had a immune response to the vaccine also appeared to be “hyper-susceptible” to HIV, causing many to ponder if an effective immunological response can ever be rendered with the rise of so-called “super-infections” (e.g. people who are infected and re-infected with new strains of HIV). If a workable vaccine is to ever be created, it would, in essence, need render a “super” immunological response to neutralise these super-infective strains of HIV. And many are doubtful that we anywhere near possessing the clinical tools needed to move forward.
Does that mean “the cure” will never come? Or that HIV has actually “beat” us at a game to which we could never possibly win? Read on. Despite the setbacks, many are starting to believe that we are winning in ways could never have imagined…
3. NEW AND DEVELOPING HIV MEDICINES
Although Truvada (a combination of the drugs Tenofovir and Emtricitabine) was introduced to the international market in 2001, it only made its way onto our shores in 2008. But in that short time, it has changed the very way that we look at HIV and the long-term goals of therapy. With the release of Truvada, we suddenly had a drug that could effectively treat patients in so-called “deep salvage” therapy (e.g. those who have become resistance to most, if not all, currently available ARVs).
Suddenly, in one fell swoop, patients who were barely managing were now given a new lease. At the 2008 Conference on Retroviruses and Opportunistic Infections, HIV researcher Dr. Sharon Walmsley went so far as to declare that “with new generation antiretrovirals… all patients are being treated as treatment-naïve” – which, in layman’s terms, is akin to discovery the means by which to become a virgin all over again.
With exaggerating, we’re suddenly at a new frontier in the development of ARVs, with drugs that are not only safer, but require fewer pills, easier dosing schedules, less side effects, and a lower propensity toward mutations and cross-resistance. New categories are being developed and released at an astonishing rate, many of which we hope to reach South Africa soon. Among them, Insentress, the first of a new class of drugs called integrase inhibitors; Intelence, the latest non-nucleoside drug similar to Nevirapine and Stocrin; Prezista, a protease inhibitor-class drug that works effectively against protease inhibitor drug resistance; and Selzentry, a new and exciting drug that prevents entry of HIV into the cell altogether.
And this is just the beginning, with a steady stream of new drugs in development, all aimed at extending both the lives and quality of life of people living with HIV. But just how long, you ask?
2. SURVIVAL RATES ON THE INCREASE
In July of 2008, Lancet published a study by Dr David Cooper which, using advance computer modeling and a retrospective cohort of HIV-positive patients, estimated life expectancy for 20-year-olds newly infected with HIV. In the article, Cooper, one of the top researchers in the world, stated that “An HIV-positive person who is started on combination antiretroviral therapy (at CD4 count over 200) at age 20 can expect to live to age 63 as compared with an HIV-negative person… who can expect to live around 80 years… while a 35-year-old could survive into their 72nd year.”
Say that again? In South Africa, where average life expectancy has fallen to 42.45 years, HIV-positive people in the developed world are living into their sixties and beyond?
But that is nowhere near the real stunner. Cooper continued by saying that “the risk of death would be diminished and overall prognosis further improved by starting anti-HIV drugs with a CD4 cell count of 500.”
And that’s, in fact, what HIV is today, or at least could be if approached in an informed, judicious manner. The risk of death could be diminished altogether. Even without a “cure,” you can’t get a better prognosis than this.
So while this doesn’t remove all the challenges or abate the responsibilities needed to turn the pandemic around, it does tell us there is more than just a little hope. We now have something to work toward in country, a goal that is reachable. And all it means is that we have to participate, to stand up, to educate ourselves.
And that’s not always an easy thing. Even in the U.S., according to a survey published in POZ Magazine, 51% of respondents still believe that HIV is a terminal disease. One can, therefore, only imagine what the impression is here given that eight long years of Mbeki denialism and the legacy that has left.
But even that, it seems, can be turned around, as we see in our Number One choice…
1. HEALTH MINISTER MANTO TSHABALALA-MSIMANG IS SACKED
Enough said. No explanation needed. Just break out the champagne and cheer!