Welcome to this November Broadsheets, summarizing recent news-making after the 2012 AIDS Conference. I have once again categorized trending stories, using the previous Broadsheets themes because they continue to be useful for organising circulating topics. Categories have also been modified to better fit emerging stories.
Where do things stand with PrEP?
Previous Broadsheets covered the U.S. FDA’s approval of Truvada, the first ARV prescribed as routine, pre-exposure prophylaxis. PrEP continues to make news, especially now as an issue of the acceptability of implementation. The Body’s slide show of opinions from the HIV community are largely positive about PrEP as an additional ‘tool in the interventionist toolkit.’ Many of the responders do qualify their support (very carefully, it might be noted) by expressing cautions, such as concerns about associated costs (especially when compared to ARV coverage for those already infected), behavioral implications, and being sure that PrEP does not supplant other strategies. The HIV+ community also expresses mixed opinions; those who are more critical of PrEP do not want the challenges of adherence and drug toxicity to be taken lightly.
Another iteration of next-generation stories are those intending to clarify just how PrEP should be used. One recent investigation asks about the extent to which PrEP requires perfect compliance (apparently it does not); another published in PLoS and reviewed by AIDS MAP, studies the costs and efficacy of PrEP compared to other intervention strategies, as a tool for middle-income countries like Peru. Despite significantly reduced infection rates through targeted use, scientists are cautious about its use without 100% treatment coverage for individuals with existing HIV infection. An overall impression generated by these studies is that while PrEP is an intervention that may have been given legs by the normative drug approval process, one that imagines use decisions as a matter taken up by providers and patients, Truvada’s use cannot be separated from policies that determine larger health service delivery issues, and HIV/AIDS intervention strategies.
The most vocal group that has to-date opposed Truvada is the AIDS Healthcare Foundation (AHF), who continues to wage and also expand their critical campaign. In recent months, AHF claimed victory when the FDA introduced language that more tightly regulated Truvada’s use. AHF also focuses its vociferous protests directly onto Truvada’s drug maker, Gilead, and members of the company’s leadership. Protesting in the streets, AHF points out the massive profits Gilead will make from the drug. In a further strategic move, AHF is currently calling upon U.S. state health departments to exclude from Medicaid reimbursement the newly FDA approved four-in-one Gilead HIV drug, Stribild, from formularies until the company lowers costs to peer (Atripla) drug pricing. (In an ironic turn, other circles praised Gilead in October for their philanthropic work in Africa.)
Another area of expansion receiving attention is diagnostic technology. In July, the FDA approved the Oraquick at-home HIV testing kit, which is now available in stores. Time Magazine named the test one of the best inventions of 2012, and basketball great, Magic Johnson’s formal endorsement received wide coverage (here too and on POZ). Like PrEP, home-based testing is not only promoted, but user acceptability is also being studied. Stories list groups’ likelihood of use (AIDS MAP reviews a Spanish study and use by MSM (picked up by KFF) and an e-Health story advocates its uptake in South Africa).
Another point of interest is the recent improvement to rapid testing accuracy and cost. Insite links to an article from the Chicago Tribune about developments made by Northwestern University scientists, and the Gates Blog cites a new test from Imperial College London (linking to Reuters) that can be used to diagnose HIV and other diseases (AIDS MAP covers too).
HIV and Healthcare Systems
Zimbabwe announced a step-down of HIV initiation from doctors to nurses, reported and reviewed by Plus News. The story was picked up by KFF, and e-Health considers using this arrangement in South Africa.
AIDS MAP and others posted that the UK’s health service delivery will now make ARVs accessible for all individuals regardless of immigration status.
Justice: Law and Protest
A prominent event of the last weeks is Canada’s Supreme Court ruling, clarifying what counts as criminal when failing to disclose one’s positive HIV status to a sexual partner. AIDS MAP has written original content summarizing the ruling, which refined the risk of transmission criteria (based on viral load and use of condoms) to determine whether individuals are legally bound to disclose their status. Divided POZ readers comment here. Canadian HIV/AIDS legal advocates have been highly critical of the ruling, linked to from AIDS MAP. The ruling was tested in early November when Steven Boone was tried and convicted of attempted murder and aggravated assault on multiple counts, including for having unprotected sex without disclosing his positive HIV status. This ruling has also been heavily criticized by HIV/AIDS activists, who argue that a penalizing environment will foment fear and stigma.
Patents are another hot issue at the moment. Slowly making its way around the blogosphere is the “quiet shift” (description overwhelmingly applied) in Indonesia’s stance on pharmaceutical patent law. Signed by presidential decree in September, President Susilo Bambang Yudhoyono is allowing the government to license HIV drug patents, taking the production of medications out of the control of prominent pharmaceutical companies. The move is intended to promote generic competition and ultimately lower drug prices. The Body, Insite, KFF, and AIDS MAP linked to the news, citing this Reuter’s article. POZ reported on the story as well, citing the Centers for Disease Control. The U.S.-based NGO, Public Citizen, has been a vocal proponent of the event, and linked to from other websites. Patents also feature in a Plus News story (picked up by Insite and KFF) that points out the consequences of South Africa’s relaxed patent office, which increases costs by allowing for renewals of intellectual property restrictions on old drugs.
As for protests, KFF reports that Zimbabweans are protesting corruption-related improper use of the national tax levied for HIV/AIDS programming. Recall that just a few months ago, UNAIDS celebrated the domestic tax as emblematic of countries taking ‘ownership’ of their HIV funding, and in February 2012, Plus News ran a story that also highlighted the benefits of these resources for HIV/AIDS programming. No follow-up comment can yet be found on either of these sites.
Counting Exercises: Targets and Funding
The Global Fund continues to receive significant coverage, its funding profoundly shaping HIV/AIDS care and treatment worldwide. After coming to a halt last year, the reinstatement of the Fund in 2012 invigorated “a management focus on impact” (taken up in the last Broadsheet). As a result, there is close monitoring of countries’ uses of Global Fund resources and their ability to achieve outcome objectives. In the last six weeks, an audit of Namibia’s use of funds was released, which found positive outcomes as well as $2.23 million that went unaccounted for and which the Fund seeks to recover. The audit was picked up by All Africa, reporting that Namibia was ‘whipped’ by the Global Fund, language that does not correspond to the audit’s descriptions, which are largely congratulatory. Moreover, the audit comes on the heels of Hillary Clinton praising Namibia for its progress with HIV/AIDS. These disconnects raise questions as to the way donor decision-making is formulated and commented upon by the variety of constituencies who engage in discourse-making.
Ethiopia’s funding was recently cut by PEPFAR and its Global Fund resources have been undisbursed, reported by KFF based on this concerned posting from the Global Health Policy blog.
In the area of lateral moves between HIV/AIDS and other diseases and health-related concerns, Plus News reports limited cervical cancer screening in Kenya, based on a recently published WHO report. Links between HIV and other determining insecurities, such as food scarcity, continue to be studied and documented, picked up by KFF.
Biomedical Topics: Vaccines
Vaccine prospects are taking center stage at the moment, spawned by recent journal publications, and vaccine conferences in Seattle and Boston. Receiving the most attention is the CAPRISA project in South Africa, which published in Nature Medicine what is considered to be a major discovery about the way immune systems can neutralize HIV. The article has been widely cited, including by Plus News ,the WSJ, the NYT, POZ, linking to a press release from the University of Witswatersrand (home of a lead researcher) and e-Health also featured a story about it. Columbia University, another institutional base, also posted material.
Another study called RV144 has also shown promising immune system findings, picked up by KFF (see Bloomberg on vaccine possibilities). The Seattle conference, organized by the Gates Foundation, presented these and related findings.
Immune science research will be given a boost by AHF’s establishment of the Institute for Immunotherapeutic Research, to be headed by a clinician and researcher Otto Yang of UCLA. The press release states that turning to immune-based sciences is the result of “the few remaining strides” with ARVs; now, big breakthrough will come about through gene therapy and vaccine research. A Canadian vaccine research bioventure has also made news from similar study objectives.
Conversations and Frictions
Online discussions have recently coalesced on the blog, ‘Science Speaks’, aiming to gather commentary from HIV/AIDS advocates about the State Department’s HIV/AIDS ‘Blueprint’ announcement by Hillary Clinton at the 2012 AIDS Conference. The Global Fund and Hufffington Post have also teamed up and launched the “The Big Push,” aimed to keep attention on the Global Fund’s financing imperatives despite the economic downtown. POZ has connected to the latter campaign.
Over the past six months of writing this Broadsheet, I have noticed that particular stories clearly grow legs; they gain traction by circulating, then posted online, and then reposted. However, despite their circulation, they seem to attract very little substantive commentary. Aside from a few areas of more overt commentary (AHF’s takedown of Gilead, protests to End AIDS at the AIDS Conference, comments made by POZ and The Body readership), AIDS activism of the past feels far from the current constellation of concerns, articulated through on-line media.
That said, two letters were recently released on-line that may expose some of the tensions simmering just below the surface of global donor programming. One critical letter (featured on KFF) was penned by members of twelve prominent health organizations to Global AIDS Coordinator, Eric Goosby, pointing out the blindspot of PEPFAR in adequately addressing HIV/AIDS among vulnerable populations (men who have sex with men, people who inject drugs, sex workers, and transgendered persons). They urge taking committed action in line with Hillary Clinton’s AIDS Conference remarks to address the HIV needs of ‘highest risk groups.’ The letter belies disappointments with marginalizing policies within and outside of the HIV/AIDS arena (e.g., the criminalized treatment of sex workers), and seeks changes in future funding structures. Another recently posted letter, this time on the AHF website, was written by advocates critiquing the Global Fund’s policy and management decisions, which may be so technocratic that it undermines its country-based effectiveness. AHF shared the letter in a press release stating that the Fund’s General Manager welcomed the input, though neither the letter, nor the open reactions, can be found on the Global Fund website to date.
Searching for differing opinions or sites of potential conflict is an emerging objective in the Broadsheet. What is at stake, and for whom, in this on-line circulating media world? One immediate issue to watch is that of global malaria funding. As reported by KFF, Plus News and others, the Global Fund and other programmatic support may have inadvertently led to a rise in inappropriate treatment. This, coupled with recent failures in malaria vaccine trials and news of wide swaths of the world experiencing drug resistance, frames what might become an uncomfortable but pressing conversation about the consequences (intended and unintended) of funding. This is a tricky conversation to have in a climate of economic austerity, where funders might want nothing more than to justify pulling back their resources. How such positions interact and become entangled will be one of many issues to watch unfold in the coming weeks.
Broadsheet News Tracking Method: After a preliminary Google Alerts search using “HIV/AIDS” and “global health” as key terms, I look up stories that appear to be getting on-line attention, especially focusing on 12 organization websites: 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); and AIDS Healthcare Foundation (AHF). I then look over additional news covered on these websites, tracking sources used.