Daily dose crucial in keeping disease in check
The anti-aids pill is out of reach for many as the push continues for a cure, write Shannon Pettypiece and Tony Jordan.
INA Bangkok go-go bar, a prostitute in a transparent miniskirt who goes by the name Joy says she’s ready to benefit from one of the biggest scientific breakthroughs in the 30-year fight against Aids.
The 23-year-old says she would like the chance to use Gilead Sciences’ pill Truvada to help protect her from becoming one of the 530,000 people in Thailand with HIV.
‘‘I am scared,’’ she said, during a break at the bar. ‘‘I want to find a husband. If it works, I’ll take it.’’
Truvada, a staple of treatment for patients with HIV, was found in 2010 to lessen the risk of infection in healthy people by as much as 94 per cent when taken regularly. As researchers struggle to develop an Aids vaccine, having a daily pill to block the virus could be a crucial interim step to rein in the disease. Yet rather than celebrating Truvada’s effectiveness, global health planners are now facing a difficult moment of soul searching over how to allocate limited resources.
‘‘On the surface it’s something amazing, you can prevent HIV with a pill,’’ said Kevin Robert Frost, chief executive officer of amfAR, The Foundation for Aids Research. ‘‘But then you start to dig deeper and it gets really complicated. When I get to the question of who pays for this I am completely dumbfounded. In developing countries, most of them can’t afford to give pills to those who are HIV positive.’’
The human immunodeficiency virus, which can cripple the body’s immune system if left untreated, killed 1.8 million people in 2010. Of the estimated 15m who needed treatment, just 6.6m in low and middle-income countries received the cocktail of drugs that can prolong lives and lower the virus to undetectable levels, according to UNAids, the UN’s programme on HIV/Aids.
To get the drugs to those already infected would cost $6 billion on top of the $16b spent fighting the virus last year.
This weekend, more than 20,000 activists and researchers will gather in Washington for the first International Aids Conference to be held in the United States in 22 years. Much of the focus of the weeklong conference will be on preventing the more than 7000 HIV infections a day worldwide, and discussion will centre on how to put the latest breakthroughs, including Truvada, into the regions where they are most needed.
Francois Venter, deputy executive director at the Wits Reproductive Health and HIV Institute in Johannesburg, said he was ‘‘blown away’’ when researchers reported in 2010 that Truvada cut the risk of healthy people contracting the virus.
Since then, though, he said he has been able to prescribe it as a preventative to only a few patients who can afford the $480-a- year cost. In South Africa, where al- most one in three people live on less than $2 a day, the drug is out of reach for most, he said.
‘‘In a general epidemic like ours, we need interventions that can be used by the general population,’’ said Venter, who works in South Africa where 5.6m people are infected. ‘‘I don’t know how you practically could do that.’’
In the US, where the median household income is more than $51,000 a year and the majority of people have health insurance, advisers to the Food and Drug Administration recommended in May that the drug gain marketing clearance as a form of prevention. The FDA is expected to make a decision in September.
At the Fenway Institute in Boston, doctors have been studying the drug in gay men and are preparing for US approval, Ken Mayer, the centre’s medical director, said earlier. About 50,000 people are newly infected with HIV yearly in the US, according to the Centres for Disease Control and Prevention in Atlanta.
‘‘There are people I take care of who are very high risk,’’ Mayer said. ‘‘I do think this could be very effective in protecting them from getting infected.’’
To do the same in Africa and Asia, though, could cost billions of dollars.
In South Africa, where about one in six adults aged 15 to 49 were infected, Venter said the entire population was at risk. Even at the lowest price for the drug, $100 a year, it would cost billions to give it to the 45m people uninfected people in the country.
‘‘Huge chunks of Africa and Asia don’t have money to pay for drugs for people already infected,’’ Venter said. ‘‘To put prevention ahead of treatment isn’t ethically responsible, and it doesn’t make sense from a financial viewpoint.’’
Timothy Hallett, a researcher at Imperial College London, said that in countries with a high incident rate, doctors would have to treat at least 50 to 100 people to prevent one infection.
In Kisumu, Kenya, where one in 10 adults are infected, Hallett and Imperial College researcher Ide Cremin found it would cost $14,000 to $20,000 to prevent one infection, assuming that half of all high-risk individuals were given Truvada.
Under that scenario, 13 per cent of infections would be averted over 10 years, he said.
‘‘You can’t get away from the fact that these drugs are quite expensive and there are all sorts of costs that go along with it,’’ Hallett said.
The cost and complexity of simply administering the drug to millions of people would be difficult, he said.
GILEAD sells Truvada in the least-developed countries at no profit and has given the rights to sell the drug to Indian generic makers to help lower the price in 112 countries, said Cara Miller, a spokeswoman for the Foster City, Californiabased company, the world’s leading maker of HIV drugs.
The treatment sells for as little as $8 a month in some low-income countries, she said by email.
Even if there were suddenly billions of dollars available to supply Truvada, the drug would not be a panacea, said Michel Alary, a professor at Universite Laval in Quebec.
Some people will not remember to take it every day, which is necessary for it to be most effective. Irregular use of the drug could result in HIV infection and foster development of resistant strains of the virus, he says.
Alary worries users may get a false sense of security if they do not understand the pill’s properties. If people cut back on condom use without taking the pill daily, reducing its protection, there could be a spike in infections. He wants governments to continue focusing the bulk of their prevention efforts on condoms, for now.
‘‘For me, it isn’t a magic bullet,’’ he said. ‘‘I don’t think it should be a priority intervention. I think the priority for preventing HIV among sex workers is to carry on with strong condom promotion.’’
While Joy, the Bangkok bar worker, said she wouldn’t have a problem remembering to take Truvada regularly, daily use would be difficult for Din, a 37-year-old male prostitute who also works in that city.
Both workers asked that their full names not be used because of the stigma attached to prostitution in Thailand.
The man was involved in a study to see if sex workers would be willing to take a daily pill or gel used before intercourse for prevention. The study, which used a placebo, was conducted by the Thai Red Cross.
Din has been working sex trade for eight years.
‘‘I know the pill is good for HIV protection, but it isn’t so convenient because I have to take it every day,’’ said the man, who does not have AIDS and always uses a condom.
The World Health Organisation plans to issue guidelines recommending the use of Truvada as prevention for men who have sex with men and couples where one partner is infected. The agency is not recommending use by sex workers yet because it does not have enough data showing it will benefit that group.
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