Why Can't We Track HIV At Home?

I make a brief return to the Washington Post’s pages this weekend with an Outlook section piece about the AIDS problem in D.C. As I say there, and in a previous posting here, I think some of the important trends got lost in the furor after last weekend’s report about a 3 percent HIV rate in the city. And there’s not much evidence of an AIDS problem that’s actually getting worse in Washington, or one that resembles problem spots in Africa.
That said, there is something elusive about what’s happening in Washington. We simply lack the surveillance tools to know if, for example, there is a new spike of infection in the city. The report offers no evidence of one, but it also doesn’t offer much in the way of contrary evidence. Because HIV takes many years to develop in AIDS, and because the D.C. surveillance systems passively rely on reports rather than seeking out trends at sentinel testing sites as is common in Africa, we’re left guessing at the most important question: How many people are getting newly infected with HIV today?
In scientific terms, this is called HIV “incidence,” as opposed to the more commonly quoted “prevalence” that merely tracks how many people are alive with the virus, no matter whether they got it last year, or during the peak of transmission in the 1980s.
Amazingly, it was easy for me to find a pretty good estimate of HIV incidence for urban Uganda. Reasonably good studies of incidence exist for many other African countries. Yet it was impossible for me to get one for Washington, D.C.
As much as I’m wary of comparisons between AIDS epidemics in Africa and the ones here, I do think that some of the tools used to guide valuable programming there should be considered for deployment here. The new D.C. HIV/AIDS report is much better than anything we’ve had for the city before, but the risk is that because that data based on old infections, we still might miss the important trends today. If we are serious about a renewed commitment to knocking down the rate of new infections, we need to know when, where and how they are happening.

AIDS in D.C.: Getting Worse? No.

Kudos to my Washington Post colleagues Jose Antonio Vargas and Darryl Fears for helping turn the spotlight on the unnervingly high HIV rate in our nation’s capital. This is a place very close to my heart. I covered D.C. politics for several years before going to Africa, and my wife and I still own a home on Capitol Hill to which we will be returning later this year.
But I am a bit uneasy with the way D.C. officials (Mayor Adrian Fenty pictured to the right) seem to be portraying what’s happening there. The 3 percent HIV rate certainly is cause for concern, but the comparisons to rates in African countries are misleading.
Here's the quote that caught my eye: "Our rates are higher than West Africa," said Shannon L. Hader, director of the District's HIV/AIDS Administration. "They're on par with Uganda and some parts of Kenya."
Those African rates are national ones, not one for a geographically compact city like Washington, D.C. If you compared to core urban rates in Uganda and Kenya they are substantially higher than what D.C. is showing. That’s even more true at the epicenter in Botswana, South Africa and Swaziland.
More importantly, the numbers of NEW AIDS cases in Washington appears to be falling fairly steadily, and has been for several years according to both last year’s AIDS report, and the new one officially released today. Check out page 22 in the 2007 report. AIDS deaths are steeply down as well.
How could this be? People with AIDS aren’t dying at such a high rate anymore, at least not in places like the United States where effective treatment with antiretroviral drugs is universally available. In places with effective treatment, the number of people LIVING with HIV will keep going up for years even if the numbers of people getting HIV is going down. In that scenario, a rising rate of people with AIDS is good news, not bad.
To my eye, the most important elements of these reports are their potential ability to guide an effective response. Not surprisingly, gay men have high infection rates. But the rates among African Americans are eye-openers and remind us of the need for more effective prevention strategies. Condoms and HIV testing are not enough.
Mayor Fenty’s push to block transmission by infected mothers to their babies is urgent. Let’s hope, however, he doesn’t shy away from discussing the sexual behaviors—especially multiple, concurrent partnerships—that drive HIV so efficiently.
Even more broadly, let’s not mistake our new awareness of the AIDS problem in D.C. with being a problem that’s truly new, or truly getting worse. I’ve watched how sloppy portrayals of the epidemics in Africa have led to poorly targeted responses. Our nation’s capital shouldn’t make the same mistakes.

Is PEPFAR Really So Great?

Dr. Joia Mukherjee, the medical director for Partners in Health, writes in the Boston Globe today about the need to fully fund the new, expanded PEPFAR, the big anti-AIDS program pioneered by President Bush. While I agree that an investment of that scale makes sense, it's not clear to me that PEPFAR, as currently conceived, is the best vehicle to do this. Couldn’t we find a better way to spend $48 billion on improving the health of Africans?

A few points:
1. This idea that PEPFAR has put 2.1 million Africans on “life-saving drugs” is simply not true. The program’s numbers, and those of most similar programs, are notoriously tricky. In addition, the best meta-analysis says that half of all Africans put on antiretroviral drugs have fallen out of those programs after 2 years. Many, if not most, are dead. And let's not forget that ARVs, though miraculous, are not cures.

2. The other, oft-cited stats are inputs, not outputs. Money spent, audiences supposedly reached, etc, are flimsy measures of success. New HIV infections are falling in some African countries, but there's no obvious relationship between PEPFAR money and falling infection rates. Perhaps the steepest drop since PEPFAR began came in Zimbabwe, which is not a PEPFAR country. Many of the biggest PEPFAR recipients, meanwhile, have not done nearly as well. Wasn’t Bush’s goal to “turn the tide” on the AIDS epidemic? Has this happened? (My take on PEPFAR last year http://tinyurl.com/awagpl).
3. There's meager evidence that PEPFAR has succeeded at preventing many new infections. Bush deserves real credit for getting the politics, and money, rolling toward widespread treatment. But in prevention programs, PEPFAR got stuck in distracting debates about condoms vs. abstinence.
4. The focus on treating people with AIDS has, no doubt inadvertantly, drained energy and money away from other similarly worthy goals. As my book project co-author Daniel Halperin wrote in the New York Times last year, as AIDS funding has skyrocketed, vital efforts on clean water, breastfeeding and family planning have stagnated or worse. Some PEPFAR money has spilled into basic health, most famously in Rwanda, but if basic health is the goal, is this program the best way to pursue it?

Now for some suggestions:
1. If we are going to put $48 billion into PEPFAR, let’s spend it much better, with a renewed emphasis on prevention programs that work. That means expanded services for male circumcision, much more effort to break up sexual networks by promoting partner reduction. Obviously the push for wider, more accessible treatment remains vital.

2. If we’re serious about saving African lives and improving African health, let’s invest intelligently in African health systems, not merely buy AIDS drugs, or send over expensive U.S. doctors, or build clinics focusing on a single disease. Let’s help build medical schools, and even better, nursing schools. Let’s work harder on medical system brain drain. And let’s make real investments in making drinking water clean, encouraging breastfeeding and making modern contraceptives (and not only condoms) easily available for everyone.

If we do these things, we’ll save and improve a lot more lives, no matter what the budget ends up being.

What do you think? Hit “Comments” below.

Multiple Concurrent Madness?

Helen Epstein's teriffic "The Invisible Cure" (http://www.invisiblecure.com/) has helped push the conversation toward the essential role played by multiple concurrent partnerships in spreading HIV, especially in Africa. I don't sense a lot of serious debate about Helen's essential point. It's clear that men and women who keep more than one sex partner in a single week or month are more likely to get HIV, and to transmit it to others, including their monogamous husbands or wives. It's a point also at the core of the ideas put forth by my friend Daniel Halperin (who is the co-author on our forthcoming book "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How To Win").
What has proven more nettlesome is translating that insight into action. The Ugandans famously did it in the late 1980s and early 1990s, but then forgot how to do it as the big AIDS money rolled in, and perhaps also as that society normalized into a more-settled postwar era (http://tinyurl.com/d7u8qe). The Zimbabweans also did it, with the help of massive economic collapse and outmigration that made keeping multiple sex partners a luxury few could afford (http://tinyurl.com/2j5kvd). But the dilemma has been, and continues to be, how do create these sorts of changes in societies not coming out of a civil war, or not going through a historic economic and social collapse?

These issues dominated a revealing conference I attended in Gaborone, Botswana in late January, and sponsored by the Harvard AIDS Prevention Research Project, UNAIDS and the World Bank. The group struggled to find a single, dominant coherent message that could be rolled out across southern Africa, a region that (aside from Zimbabwe) has been notoriously poor at talking directly about the sexual behaviors that spread HIV particularly fast there.
I've been keeping tabs on the conversations that flowed out of that conference, and the effort to draft a solid, concise document that can be distributed around the region. My old friend Francois Venter, president of the Southern African HIV Clinicians Society, blasted the original effort in a blistering blast email. His point, in short, was: Everybody is sick of being told what to do (condoms/HIV testing/etc). If you are going to come forward now with another idea, it better be rooted in rock-solid, demonstrable science, with clear guidance on how to turn it into effective programs.
On this, I mostly agree. The science has to careful, the arguments rigorous and well-explained. But I'd like to think that, thanks to Helen and others, that even Francois would agree that the most urgent questions in AIDS prevention today has to be: How can we help change the sexual behaviors that are most dangerous? As a first step, don't we have a moral responsibility to make clear what these are?
I've spent dozens upon dozens of hours in bars/shebeens all over southern Africa talking about this stuff. And inevitably I end up flipping my notebook over and drawing a simple diagram of a sexual network, with my interviewee in the center in an expanding spiderweb of interactions. Not once has somebody failed to express surprise. A quarter century into the world's response to the epidemic in African, shouldn't everybody in these hardest-hit nations be familiar with this stuff. If they aren't, whose fault is it?

The good/bad news about vaginal microbicides

I join everybody in applauding the news that the microbicide people are making progress in their quest to find a better female-controlled HIV-prevention device. But no one yet has answered the deeper and harder question: How do you get people to use it?
Elizabeth Pisani nails the happy side of the development announced last month at the CROI Conference in Montreal: http://www.wisdomofwhores.com/2009/02/10/significant-progress-in-hiv-prevention/
But at least as valuable is this piece by the gang at CADRE in Johannesburg, where they have watched the rise and fall of many of the supposed solutions to the AIDS crisis. Take a look at their reservations about microbicide research: http://www.cadre.org.za/files/Parker%20Colvin%20Microbicides%20Durban%20Conference%20A267%20low%20res.pdf
I fear that microbicides, and the one-a-day prevention pills that also are showing signs of technical success, amount to just building a better condom. Sure they stop HIV, but only if people use them almost constantly, with all sex partners, in every interaction. Microbicides certainly have the advantage of more female control, though I'm skeptical that men won't know that their sex partners suddenly are inserting a new substance in their vaginas. I can recall interviewing couples in Durban a couple of years back about Microbicide use during trials, and the men definitely could tell the difference. In most cases, they liked the extra lubrication, which might be a secret marketing advantage for microbicides IF you can get people to start using them.
In any case, the technological problems will not be the hardest ones to solve for Microbicides. As with most everything having to do with AIDS in Africa, the solutions are going to have to mesh with cultures almost totally unfamiliar to the Westerners in charge of the AIDS war.
What do you think?

Welcome

Welcome to Craig Timberg's personal blog. Here you will find links to my favorite stories that I've written for the Washington Post, about wars, famines, and dictatorships, as well as rock bands, gold pirates, guys who blow up ATM machines and a Nigerian who built a concrete 737 on the roof of his house. But my work these days is focused on the AIDS epidemic in Africa, which by my reckoning is going disastrously despite the world's unprecedented financial and political commitments to the problem. I'm on leave from the Post for a year while I write, along with my co-author Daniel Halperin, "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How to Win."
Daniel is an epidemiologist and medical anthropologist, as well as a veteran of the political battles over AIDS, within the Bush Administration and more recently on a world stage as an oft-quoted expert from the Harvard AIDS Prevention Research Project. (http://www.harvardaidsprp.org/daniel-halperin.html).
I'll use this space to update everybody on our work, and I'll sprinkle in some interesting issues and discoveries along the way. Please keep reading. AIDS already has been around for a century. But we've probably never been closer to figuring out how to bring it under control.