Welcome to the second Broadsheets “Cut and Clip,” covering news made between mid-May and mid-June, 2012.
Topics covered in the first posting were arranged under the headings: (1) treatment liberalization; (2) HIV and Health Systems Strengthening; (3) HIV and the Law; (4) Counting – Targets and Funding; (5) Pragmatics of Access; (6) Synergies; (7) Some National HIV-Related Initiatives Making Headlines; and (8) Global Health Trends. Here, we follow up on the headings and the stories that continue to “make news.” We also add new headlines. You will find one additional category called (9) Biomedical Topics[*].
You’ll remember from the first post that in addition to summarizing the news, Transcriptions also aims to track how news spreads (or conversely, falls flat). Soon, we will reflect upon these movements in an independent posting; for now, you will find embedded commentary that begins to link posts in order to describe the traveling of content.
(1): Treatment Liberalization
Interest continues to gather on the issue of ART availability for wider populations because of changing criteria for its prescription (e.g., lower initiation criteria and pre-exposure prophylaxis or PrEP). At the forefront in the US is the question of whether the first HIV drug (Truvada) will be approved for PrEP use. Since the last posting, increasing debates about PrEP’s advantages and disadvantages can be heard on the wires. Poz’s review of the May 10 Advisory Panel shows that there were more divergent perspectives than the Panel’s eventual consolidated recommendation, as well as the tone of mainstream news in its wake. David Evans blogging on Poz recently posted (here) measured support for PrEP, which provided an opportunity for diverse reader comments, suggesting that the American HIV/AIDS community is all but resolved on whether it’s a good idea. Denis Grady’s piece in the NYT (posted on KFF) laid out some controversies too, followed by a variety of responses, particularly around the question of whether the public should pay for the bad choices of others.
As for where things stand regarding the approval process of Truvada, last week the FDA announced a postponement of a final decision until September (see the Body post and Insite link). Gilead explained that the delay was expected, given that they submitted supplemental language for review regarding how a negative HIV test must accompany each prescription. The AIDS Healthcare Foundation, a central opponent of PrEP, finds this submission a victory, announced through a press release on their site, and the news was picked up by the AP featured in this article in Bloomberg Businessweek, and then by other newsfeeds.
(To add to the drama, AHF further released a press statement that Gilead pulled their funding from AHF due to the PrEP squabbles; see this “story” on MarketWatch (Poz and Insite picked this up). Gilead has not commented as far as we can find.
The US debates have so far been largely separated from concerns voiced in the international arena, but AIDS Map brings them into the conversation in postings like this one. Various positions can also be found here, written by an AIDS Map staffer who summarized discussions that took place during IAPAC’s “Controlling the HIV Pandemic with Antiretrovirals Evidence Summit” in London in early June. A number of relevant and sobering issues were raised. A general view was taken that different contexts need to be taken into account when devising biomedical standards, given access unevenness and the ways that it will shape treatment as prevention. This led to suggestions that even in places where ARVs appear to be secure, links to care are not. The point was also made that health systems are placed under enormous pressure when treatment access is scaled up given worker shortages and systems-development issues. Other concerns include the handling of side effects, first versus second line therapy availability and quality of treatment, and drug resistance. Finally, one speaker talked about how HIV infection has been criminalized in some places, which could result in making treatment coercive. We will continue to watch these issues unfold across the HIV/AIDS-affected landscape in light of the FDA approval, as well as the WHO and other developing positions on ‘TASP’ (the broader term to use ARVs as prevention – see here).
(4): Counting – targeting and funding
In this period, we find familiar reports of increasing and decreasing infection rates. Testing in Ethiopia is reportedly increasing (PlusNews) and UNAIDS notes Zimbabwe’s successes as well. Others are noted, too numerous to reasonably track. We will in future post a link to sites tracking these updates in real time.
Targets and funding directions come together for UNAIDS with calls to end new HIV pediatric infections through “Believe it. Do it.” The campaign is consistent with the US State Department’s “AIDS Free Generation” initiative. These institutions may be devising approaches based on evidence that shows great “bang for the buck” for PMTCT, or so reports KFF, drawing upon this blog. The writer, Scott Kellerman, also ties in WHO’s newest guidelines recommending therapy commencement for all HIV- infected pregnant women regardless of lab values. Here, we glimpse how links between interventions are both real, and are also made by those contributing to the media. Kellerman also cites his own successful work in Malawi with pregnant women as a case study of effective amplifications of PMTCT. Now at this time, Plus News reports that the new Malawian president, Joyce Banda, is taking important steps to rekindle positive relationships with international donors after the denial of aid for the past few years. What are the connections here (if there are any)?
A Word about Circulations…
An article is circulating that Brazil, a front-runner in demonstrating political commitment to ARV treatment access, may end its robust support for HIV/AIDS programs given rising costs and a new president’s persuasions. The Body picked up the story, as did Insite through KFF Policy’s Report, which in turn linked back to the original Miami Herald article that drove this news. The story uses persuasive statements made by the President of the Brazilian Interdisciplinary AIDS Association (an anthropologist), who describes the imminent “destructuring” of the national program. While this may be entirely true, evidence in the article shows little to no support for this position. It was written by a journalism student, and perhaps should have been more carefully vetted. However, the point for us is that the article has been linked without commentary here, here, here, and here.
(5): Pragmatics of Access (and Distribution)
As mentioned, PrEP as technological “game-changer” stands in opposition to the numerous access and distribution shortfalls that we might consider the persistent drag of the HIV/AIDS epidemic. Last month, we reported dangerous shortfalls of drug supplies in South Africa. It appears that due to outcry, this has at least in part been addressed, as reported by e-Health. (Four drug companies are supplying drugs and Mark Heywood of the Treatment Action Campaign is quoted as laying blame at the door of the Department of Health, which needs to provide better oversight as the “custodian of people’s lives.”) Yet, there’s another worrying report from AIDS MAP about delayed access to second line treatment in South Africa, as first line resistances develop. Another facet of this mal-distributed global economy catches the light.
(7): National Policy Items
Plus News reports: Support but limited funding is available to advance male circumcision in Uganda and free needle distribution to injection drug users throughout Kenya. Decentralization and coordination of MDR-TB (along with HIV) therapies are now beginning to happen in South Africa, as a response to worker shortages, and revamped biomedical therapeutic protocols. (This last story was not picked up by e-Health, a site devoted to South African health news; restructured healthcare on the national level would seem like it might be a main event, so what does the silence show us about the story? Questions to be explored in the coming post.)
(8): Global Health Trends
A recent feature by Mark Dybul, Peter Piot, and Julio Frenk argues for the re-design of global health, what they call a new ‘global health architecture.’ Central elements include the much needed coordination among donors, greater local “ownership” of healthcare (i.e., less ‘paternalism’), and greater financial responsibility overall, re-distributed around globally rationalized priorities. Andrew Harmer reacts on his blog in a critical way, and KFF includes both pieces in their reporting.
The focus on fiscal pragmatism, germane to the global financial crisis, might explain the post here, an editorial by the University of Pennsylvania Provost Ezekiel Emanuel, evaluating a recent study evaluating PEPFAR and its achievements (a widely circulating study not unlike the Rwandan one in our first post about strengthened health systems from donor driven HIV interventions; researchers and policy makers appear to be all ears). While Emanuel finds the study itself to be sound and so PEPFAR may claim success, his more salient question is, “Is the investment in PEPFAR worth it?” By this, he means that success cannot be determined by lives saved, and not along one disease axis. Rather, he calls us to ask about improved health overall, comparatively assessing intervention impact, and taking into account a fiscal efficiency criterion.
Basing intervention decisions on literal “value added” is quite obviously a playing field for economists, and a minefield for social scientists, a debate we will side-step (for now). What we note is how the particular presentation of financial concerns hope not to undermine technological prospects, be they articulated through the technologies of intervention, of evaluation, or perhaps most forcefully, of the ever-broadening potential of hi-tech pharma. All of this is mediated in a tense dialogue with some version of access and equity ethics (see Marsha Rosengaarten’s recent post on this blog). Each component up for consideration is not meant to undo the others given the imperative of economic pragmatism, but to spawn creative thinking. Calls for prizes to facilitate open-source and patent-less (and not too costly) discoveries may fit in at this intersection.
And at this nexus is another view on the productive, and potentially innovative use of hi-tech innovation within an economically responsible framework, especially in lower income countries that struggle with a high disease burden. Here, the view is that, with capital investment and knowledge transfer, domestic production of pharmaceuticals and other in-demand health products can energize local markets, while leading to domestic financing mechanisms for HIV/AIDS, and in turn ending dependence on Western aid. UNAIDS is taking this position and in fact, their identification of Zimbabwe’s success mentioned earlier not only showcased decreases in HIV rates, but the nation was also congratulated for implementing a tax levy to support their programs domestically.) In Executive Director Michael Sidibé’s recent presentation, innovation can be owned, independent, economically savvy, and thoroughly in keeping with present-day techno-promises in an (ailing) world replete with increasing, econometric formulas to orchestrate “successful” relations.
Also…(9) Bioemedicine Topics
Finally – in the lead up to the International AIDS Conference, we note:
Another tool in the expanding diagnostic and therapeutic approach to HIV is the HIV home-testing kit, also up for FDA approval. One blogger on the Body disapproves of home-testing, and has set up a facebook page to gather support (so far, only generating 43 “likes” as of June 15).
Cure is back in a strong way at the moment. A central story (from National Public Radio, but featured on Insite and POZ) pertains to a German HIV positive man who, post-bone marrow treatment for Leukemia, appears to have been cured of HIV. Some doubt has arisen, however, as to whether HIV remains in his body, sparking concerns about whether he was “really cured,” and what this means for the prospects of cure more generally.
On the wires over the last few weeks has also been reactions to an editorial that ran in PLoS in late May calling Chagas disease a new HIV/AIDS. The outcry at the clumsy comparison led the first author to say that the piece was meant to stir controversy. (For a recently published intellectual history of Chagas, see Delaporte 2012.)
There will be one more roundup prior to the International AIDS Conference, taking place from July 17-22. The conference will receive its own post.
[*] Reminder: In addition to following news through the Google Alert Reader App, the 12 organizations initially being tracked to see how stories are made and move are: UNAIDS, IRIN Plus News (Plus News), Kaiser Family Foundation (KFF), University of California San Francisco HIV Insite (Insite), NAM AIDS MAP (AIDS MAP), Health-e, The Body, POZ, Global Fund, International HIV/AIDS Alliance (Alliance), Bill and Melinda Gates Foundation (Gates’ blog); AIDS Healthcare Foundation (AHF).