Thursday, April 8, 2010

Mila Rosenthal, HealthRight's Executive Director, Quoted in Financial Times about HIV Prevention

"Prevention: simple solutions offer most promise"

November 30, 2009   By Andrew Jack

For all the research to find sophisticated new ways of limiting the spread of HIV, some of the most simple and longest-established prevention techniques offer the greatest potential. With better targeting, they could be far more effective still.

The “holy grail” of an HIV vaccine still remains a distant dream, despite the modest apparent protection identified in one trial in Thailand earlier this year. Microbicides – vaginal gels designed to kill the virus – have failed in a series of expensive clinical trials.

But Stefano Bertozzi, new head of HIV at the Bill & Melinda Gates Foundation, says: “Making use of all currently available prevention strategies could avert more than half of the infections projected to occur over the next decade.”

Condoms are an obvious, low-cost example. With more than 4bn produced around the world each year, they play an important role in preventing the transmission of infection. But they could play a bigger part.

Peter Roach, who runs social programmes for the Durex Network, funded by one of the world’s largest manufacturers, says the form and distribution of the 1bn annual global “public health condoms” must be re-thought. They are bland, standardised and smell of latex, he says.

Another approach is education campaigns to improve understanding of HIV and how to reduce transmission by encouraging abstinence, fidelity and use of condoms. Yet religious and moral objections – including in the US – have limited the balanced presentation of such approaches.

Even with full information, changing behaviour remains challenging, as the continued rise of infection in British gay men – who have been exhaustively targeted – illustrates.

Surveys highlight widespread and continued ignorance. “The messaging has to be constant,” says Mr Roach. “Governments run three-month campaigns but young people become sexually active every day of the year.”

A promising third approach is circumcision, long practised in cultures with a lower HIV prevalence, including among Muslims and some African tribes. Yet only in the past three years have a handful of clinical studies shown transmission from women to men cut by 60 per cent, and several countries have launched programmes encouraging the procedure.

“Harm reduction” programmes target transmission caused by infected syringes passed between drug addicts. Needle exchange programmes, which give users clean needles, reduce such sharing, while the substitution of orally taken methadone for heroin offers another way of cutting HIV rates. Yet in central Asia and Russia, for example, political hostility limits such work.

One of the most effective ways to limit the spread of HIV is through the prevention of mother-to-child transmission. A simple application of antiretroviral therapies to the pregnant mother ahead of birth, and the child shortly after, coupled with avoidance of breast-feeding, very sharply cuts the likelihood of an HIV-positive mother giving the virus to her child. Yet fewer than half of those at risk in low- and middle-income countries receive the treatment.

Nicholas Hellmann, executive vice-president of medical and scientific affairs at the Elizabeth Glaser Pediatric Aids Foundation, says: “There is an incredible body of data, but the impetus to increase coverage is slow to materialise.”

While one of the drugs – Boehringer Ingelheim’s nevirapine – is widely donated by the company, a scarcity of clinics and health specialists in many developing countries limits its broader use. “It’s such a no-brainer,” says Mr Hellman. “We have excellent technology, but the scale-up is the real challenge. We could eliminate pediatric HIV.”

A final important tool for prevention is HIV testing. Estimates suggest that a third of Europeans who are infected remain ignorant of the fact. That not only makes their own treatment more difficult when symptoms trigger a diagnosis, but also risks unwitting spread of the virus.

But Mila Rosenthal, executive director of Healthright International, a New York-based charity, argues that testing cannot be taken in isolation. In poorer countries, where a positive result does not automatically led to treatment and stigma is high, the incentives to participate are limited. “The huge uptake in testing is only giving us more data on prevalence rates, not creating a lot more access to treatment,” she says.

While many argue that there is a trade-off for scarce resources between prevention and treatment, drugs can also help prevention. A clinical study called PREP currently under way is examining the use of the medicine tenofovir as a prophylactic. Recent mathematical modelling suggests that if treatment is sufficiently widespread, it in itself reduces the risk of transmission.

In the long term, treatment could become the new prevention. But for now, existing prevention methods need to be much better understood and more tightly applied to those groups most in need.

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