Monthly Archives: December 2013

HIV Transmission: Treatment or Behavior Change Interventions?

Joy Lee attended November’s Point/Counterpoint seminar with Robert Grant, MD, MPH from UCSF and Myron Cohen, MD from UNC. The event was moderated by Victoria A. Cargill, MD, MSCE from Office of AIDS Research, NIH. Joy bring us this recap of the debate:

The audience at the Point/Counterpoint seminar

It goes without saying that AIDS is one of the largest issues in global health – one can even note that the epidemic itself created the platform of global health. In the last 30 years, we have come a long way in pushing back against AIDS through biological research, community and social planning strategies, and education. However, AIDS still presents itself as a challenge due to how widespread it is; no continent is free from the virus, and even in the United States, every state has a significant population that is affected (Cargill). Since resources are limited and there is always a cap to funding, how do organizations decide where to best spend their efforts, and what should health practitioners advocate for?

First up on the podium is Dr. Cohen, who gets straight to the point and fires off his well-prepared bullet points on the benefits of antiretroviral therapy (ART), multiple research studies that prove his point, and the well-rounded advantages from ART. “The best thing that we can do is treat everyone, and treat everyone immediately,” Cohen asserts, citing studies done with discordant HIV couples, where transmission is seen the most. With ART, virus replication can be suppressed in secretions and HIV transmission can be blocked, and it also benefits individuals who are not yet at the threshold of the CD4 count. Cohen’s top priority is to give the pills to everyone, and the earlier people start, the better; even individuals without strong symptoms can start ART and contribute to lowering the percentage of viral infections in the population. By decreasing the prevalence, this also contributes to the scientific research that is dedicated to finding a cure. In addition to the health and biological benefits, there seems to be a positive correlation between CD4 count and GDP and employment rate, at least in the United States. Thus, Cohen states, by tackling AIDS as a biological issue with ART, the health community can practically move forward and attempt to contain the spread while in search of other treatments.

Dr. Grant takes to heart what Dr. Cohen says, agreeing that the different ART treatments (i.e. TasP, PrEP) are needed, and do have an effect,  but it is not enough to view AIDS as merely a biological condition. “Prevention is a diverse portfolio,” Grant iterates repeatedly, pointing out that social benefits and consequences of AIDS cannot be ignored, and that communities that are at the heart of the epidemic are unique and cannot be dealt with uniformly. An example community is the city of San Francisco, home to a strong community of public health researchers and practitioners, yet the fight against AIDS is still going strong, and does not seem to be ending. If ART was the answer, then the SF community should show positive results, but it does not seem to be the case. Grant demonstrates this point by showing a schematic iceberg, in which the HIV status of an individual is only the tip, and other competing factors such as community and family planning, nutrition, socioeconomic status, and emotional understanding of the epidemic lie beneath the surface. If we are to deal with the upcoming 34 million individuals who are fighting this battle, we need to look at all the needs, and not just the biological concerns.

Dr. Cohen is allowed a five minute rebuttal, and focuses the debate back on the fact that AIDS should first and foremost be seen as a medical condition, and therefore the most important issue is to deal with how to reduce transmissions globally, and not just in the United States. Cohen concedes that the idea of combination prevention is appealing, but due to our currently limited knowledge, resources, and funding, it is not a sustainable solution. In his rebuttal against the rebuttal, Dr. Grant reminds us that although it is a medical concern, AIDS cannot be fully studied through randomized trails, because each environment holds a different scenario, and thus all aspects need to be considered. In addition to this, by hitting people with ART “early and hard,” there is also the issue of drug resistance, since individuals who do not experience strong symptoms cannot be guaranteed to adhere with strict compliance.

What do you think? It’s never too late to make a difference!

Joy Lee is a Clinical Research Coordinator in Ophthalmology at the University of Pennsylvania