Test and Treat…And Then What?

The only way we get through life with any semblance of sanity is through compartmentalization. Everyone of us has hundreds of different spheres and categories into which we make sense of our lives. Each weekday morning, most of us leave our home lives and significant others or nuclear families to head to our work lives with our work friends and bosses and tasks that range from significant to menial and everywhere in-between. If we go to the theater we inevitable suspend our disbelief for 2-3 hours as we lose ourself in the world of drama only to step out into the real world and walk to our real cars where we lose ourselves in the rhythms of the road taking routes home that have been ingrained in us to the point that we take turns as a reflex while our musical selves are stimulated by the radio. Our brains are unknowably complex labyrinths of synapses and sections that hums along at a million miles a minute only through the evolutionary grace that allows us to unconsciously make some sort of sense out of everything around us. It’s why when someone takes LSD they inevitably dissociate and get confused because the boundaries of their senses go into flux and suddenly they can see sounds and taste smells in ways that through their entire orbit out of whack. We are creatures of habit and order and we almost always look for simple solutions to complex problems because we believe that is the way things ought to be even if they’re not.

Ever since Human Immunodeficiency Virus was found, back when it wasn’t even HIV or AIDS but GRIDS (Gay Related Immune Deficiency Syndrome), we’ve been looking for a cure just as we have for all other illnesses since men and women first knew what sickness was. In the mid-90s, the breakthrough that the AIDS community was waiting for arrived in the form of the white knight of anti-retroviral therapy (ART). Even then, in the early days of the AIDS cocktail when waking up at 3 in the morning every day to take a handful of pills that made you feel sicker than the AIDS did was the norm, scientists and patients pressed on in the hope that there would be a day when life might return to something like it was before this mess started; before Freddie Mercury and Magic Johnson and before red ribbons meant anything to anybody. Science would surely save the day.

Now, it’s 2012. We have a whole arsenal of pills that can decimate any trace of HIV in a person’s blood stream save those nooked and crannied dormant cells that do nothing but let us all know the disease hasn’t left just yet. The side effects can be uncomfortable, but they’re for the most part manageable and on a par with other pharmaceuticals used to treat other common illnesses. We have a surefire way to render HIV undetectable in the blood stream and nearly impossible to transmit. So, why don’t the numbers move? Why does the HIV incidence in America stubbornly hover around 50,000 newly HIV+ people a year despite our myriad scientific advances? Why aren’t we winning?

Pre-exposure prophylaxis is just one aspect of the approach needed to curb HIV incidence at home and abroad.

The answer has to do with compartmentalization. Ending the HIV epidemic goes well beyond HIV. At a certain level it has very little to do with HIV. In a recent article on the potential impact of test-and-treat strategies in controlling HIV infection, Gardner et al (2011)posited that engagement in care, just as much as the nature of the care itself, is crucial in stemming the HIV epidemic. And how does one go about keeping clients in care? Well, first an HIV+ person has to be diagnosed. Then, he or she needs to be engaged in HIV care, leading to the initiation of HIV treatment, which eventually leads to the ultimate goal of viral suppression. The client then has to remain in care and maintain viral suppression for the rest of their life, however long it may last. Finding the right mix of medication to suppress a patient’s viral load is only one part of the puzzle . No matter how effective pharmaceutical companies can make their meds, people must first be tested, diagnosed, convinced to enter care, and then kept in care while effectively following their treatment regimen. Gardner shows in his study that affecting change in one of those areas does little to affect change on the whole if the other issues are not addressed.

So, what recommendations are given for improving treatment outcomes? Well, for starters, clients are going to need intensive case management services to get them into care, buttressed with substance abuse treatment opportunities, housing and transportation assistance, mental health services, life skills training, home outreach services, literacy training along with an overhaul of the healthcare system in general. And this doesn’t even begin to address the barriers placed in the way of HIV providers and clients by stigma surrounding the disease and financial issues affecting much of the HIV+ population. As it turns out, the plan of action is rather simple: the only thing we have to change is everything.

The point of all this is not to make the climb seem so daunting that we ought not to bother making it. Far from it. At the core of the HIV dilemma is the fact that it is a societal issue and a moral issue just as much as it is a public health issue. While some diseases like hypertension and some forms of cancer tend to be more prevalent in lower-income and minority individuals, few of them can hold a candle to HIV’s disproportionate effect on the poor and marginalized in our society. The HIV prevalence for blacks in America is eight times that of whites and for all racial groups in urban areas, the likelihood of contracting HIV is doubled (2.4% vs. 1.2%) if a person is living below the poverty line1.

Much has been made recently of a panel recommendation to the FDA that the anti-retroviral drug Truvada be used as a preventative measure in the fight against HIV. Those in favor of the recommendation say that using Truvada as pre-exposure prophylaxis (PrEP) could help stem the tide of the HIV epidemic and gives consumers another way to protect themselves from the virus. Opponents say that with the current high rates of non-adherence to medication, using the drug off-label as PrEP would only increase the number of people who would could eventually carry strains of HIV that are resistant to certain medications. For what its worth, Gardner and other experts generally come down I favor of this new test-and-treat strategy, albeit with some trepidation and the warning that this plan is far from a panacea.

As a recent New York Times article illustrates2, the case for Truvada as a preemptive prevention tactic amongst HIV negative individuals is not so cut and dry. It’s not exactly like taking a baby Aspirin every morning to ward off heart attacks. The drug can cause severe stomach upset for the first few weeks of use and requires regular testing to monitor client kidney function and, in rare cases, bone thinning. Beyond that, there is the fear that through misinformation or neglect, clients will assume that taking Truvada negates the need for condom use, which could lead to increased spread of other STIs. However, despite all of these issues and the possibility of viral drug resistance, the consensus thus far is that a medication as prevention approach in high-risk populations can be quite successful.

One thing that is for certain is that the Test-and-Treat method of prevention is not a silver bullet anymore than the introduction of the first effective ART drugs was. Pre-exposure Prophylaxis is simply one part of a very complicated continuum of care that is crucial in creating positive change for the HIV community in American and across the globe. Earlier this year, the Milton Hershey School refused admission to a young boy because he was HIV positive, while Burger King has recently fired one of its managers almost immediately after her came forward about his serostatus. There is no pill that eradicates ignorance. No laboratory experiment or laboratory study can wipe away fear and prejudice. Pharmaceutical companies can’t create a drug to alleviate poverty and urban blight. Test-and-Treat is but one small element of a systemic problem. Our hope lies in the chance that through this one spoke the entire wheel is illuminated.

1Treston, C. (2010, July 10). Cdc study on poverty and hiv rates in inner-city neighborhoods: Familiar story to some, still unacceptable!. Retrieved from http://www.thebody.com/content/art57782.html

2Grady, D. (2012, May 14). Taking truvada to prevent h.i.v. also comes with risks. The New York Times. Retrieved from http://www.nytimes.com/2012/05/15/health/policy/taking-truvada-to-prevent-hiv-also-comes-with-risks.html?_r=1

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