Is Treatment Becoming the New Prevention Fad for HIV & AIDS?

Two new studies (one in Kenya and Uganda, the other in Botswana) were published this weeksuggesting that administering HIV antiretroviral (ARV) drugs to the general population could reduce the risks of HIV transmission by 60-70%.

In May we reported on a study that showed this worked for reducing infection rates between sero-dsicordant couples (i.e. where one is HIV+ and the other is uninfected). These newer studies however, suggest that making ARVs available to the general population in communities where there is a high incidence of HIV infection could dramatically reduce the rate of infection overall.

There are big questions about the reality of turning this into a realistic and ethical prevention strategy. Firstly, it does not always work – an earlier study (FEM-PrEP) using the same drug as the Botswanan study (Truvada) showed no impact. The reasons for that disparity are unclear, but may have to do withadherence – i.e. the benefits disappear if the drugs are not taken consistently.

Secondly, there is the cost – ARVs are still not cheap, and making them available to uninfected people when the majority of those with an AIDS diagnosis worldwide cannot get access to them raises real questions about affordability and the ethics of how aid money is distributed. In other words, given limited funding, do you invest in helping those who are already ill, or in stopping some of those who might get ill from becoming infected?

Thirdly, is it ethical to make available drugs (with all their side effects) to otherwise healthy people? Especially if, in doing so there is a risk that we could undermine other proven strategies such as partner reduction (so called ‘zero grazing’), abstinence and condom usage?

Using HIV antiretroviral therapy as a prevention strategy is rapidly gaining a body of supporting evidence. This is good news, as the argument for getting more people on to ARVs worldwide is boosted – it not only saves the lives of the infected, but reduces the rate of new infections. This gives added weight to efforts to get 15 million people living with AIDS on to ARV by 2015.

At the same time, if this happens at the cost of the massive gains in more comprehensive prevention strategies, we could find ourselves back peddling on the progress made in prevention initiatives over the last two decades. These initiatives have shown that not only behaviour change and treatment are important, but community engagement and awareness, government commitment and a partnership with civil society, including the churches, is vital.

Let us hope that the global community proceeds wisely with its growing tool box to tackle the HIV & AIDS pandemic, and does not forget the hard learned lessons of the last three decades.

this post originally appeared on the blog of the Christian Medical Fellowship UK

A surprisingly upbeat end to the UN high level meeting on AIDS promises renewed global action

UN meetings and political declarations are often perceived as wordy and irrelevant. But every now and again these high level meetings do come up with statements that shape the actions of governments and aid agencies for years to come. The Millennium Summit of 2000 was one of these occasions, when the Millennium Development Goals were agreed. The UN General Assembly Special Session (UNGASS) High Level Session Declaration of Commitment on HIV and AIDS last week may well be another.

Those present from British NGOs and faith organisations had feared yet another fudge, but instead we got a commitment to getting 15 million people on HIV antiretroviral treatment by 2015. Granted, the commitment was only to ‘work towards’ that target, and there was no detail on how it would be funded or sustained. However a target has been publicly agreed, one to which governments and the UN can and should be held accountable.

There were other positives, in particular a lot of discussion and acknowledgement of the importance of faith based responses (even if they get little mention in the declaration text). There was also recognition that thirty years of responding to HIV means the global community has learnt a lot about how to deal with a major international health issue – learning that needs to be shared and used in other health issues.

But the big surprise was saved for the Secretary General, Ban Ki Moon who announced that the high level targets were to be what is becoming known as the ‘Three Zeroes’ – zero new infections, zero AIDS related deaths and zero stigma by 2020. These may be impossible targets to achieve, but as the saying goes, ‘aim for the stars and you may reach the moon’. And more significantly, it is the first target to be publicly announced by the UN that takes any of the Millennium Development Goals past 2015.

Of course, the devil will be in the detail of how these targets get turned into actions, but they do give us some specifics with which to hold our own governments and global bodies accountable.

an earlier version of this post originally appeared on the Blog of the UK Christian Medical Fellowship - www.cmfblog.org.uk

HIV & AIDS treatment as the new Prevention Tool: new findings should be treated with caution

News broke in the morning of Friday 13th May 2011 of the results of a ten year study by the United States National Institutes for Health (NIH) into the impact of early antiretroviral treatment (ART) for people living with HIV infection on reducing their risk of transmitting the virus to their sexual partners. Setting up two groups of 800-900 serodiscordant couples (i.e. where one was HIV+ and the other was not) from different countries around the world, one group was treated with ART while still healthy, with high CD4 white cell counts and no clinical symptoms, while the other group were treated according to current clinical guidelines. Both groups were given advice on safer sex to reduce risks of infecting the HIV negative partner.
Six years into the study it was stopped because the results were so dramatic. The chances of HIV transmission amongst those on early ART were 96% less than amongst the control group.

The results were so startling that it led Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) to say “This breakthrough is a serious game changer and will drive the prevention revolution forward. It makes HIV treatment a new priority prevention option.”

It is heartening news when any study shows that a single intervention can have such a significant impact on something as life threatening as the transmission of the Human Immunodeficiency Virus, and we should be cheered to see a long held maxim – that HIV treatment is a key prevention tool – at last have some strong evidence to back it up.

However, we should perhaps treat these results with some caution. As the NIH points out, after six years a total of 39 cases of HIV infection were found among the previously uninfected partners of HIV positive study subjects. Of those, 28 were linked through genetic analysis to the HIV-infected partner as the source of infection. Seven infections were not linked to the HIV-infected partner, and four infections are still undergoing analysis. So in at least seven cases, HIV was acquired from another source – probably another sexual partner, or through IV drug use.

In other words, for a small minority of at least seven people in this study, the fact that their partner was or was not on ART had nothing to do with their acquisition of HIV infection – it was their own personal behaviour that was the risk factor. And this illustrates the danger of jumping onto a single intervention.  It is widely recognised that faithfully married wives are often most at risk of HIV infection in many parts of Africa and Asia, because their husbands are sleeping around – it is their husband’s behaviour that puts them at risk, not their own.  Intermittent use of condoms only with ‘non-regular’ sex partners is another route by which HIV gets transmitted, particularly in parts of southern Africa, where it is not uncommon for men and women to have more than one regular sexual partner who would be considered ‘safe’ enough not to warrant condom use – ART would make only a marginal impact in such a situation.

In short, the danger is that in focusing on one bit of genuinely good news, we can forget that HIV prevention is about multiple interventions – human behaviour is not so easily put in boxes, especially when it comes to sex. Focusing on condoms or male circumcision or delayed sexual debut alone does not make for an effective HIV prevention strategy, as countless years of research as shown. They all play a part, for sure, but investment in strategies to encourage behaviour changes – especially to encourage sexual abstinence outside of and mutual fidelity within a lifelong relationship – effective treatment and care, strategies to combat stigma and fear, and to equip and mobilise communities to respond together, are all needed. The twofold danger with the reaction to this finding could be a myopic focus by funders on ART as the main prevention tool, or of people on ART believing that they are not an infection risk and behaving in a manner that would put themselves and others at risk.

And there is a third danger. This study was stopped after six years – so we do not know of the long term consequences of early ART. What of the impact on viral resistance and the limitations this will bring to later treatment option? Will more resistant viral strains be transmitted by those on early ART? And will the funding be sustainable to keep people on ART for the rest of their lives.

Christian responses to HIV continue to emphasise a wide ranging, socially responsible and sustainable response to HIV and AIDS, recognising that our behaviour and choices as individuals, societies and as a global community have an impact on one another. We should greet the news that there is a new tool in the prevention arsenal as a positive development, but not take our eye off the ball with the other interventions and our own long term commitment to tackle this awful pandemic.

This post originally appeared on the official blog of the UK Christian Medical Fellowship

ICMDA HIV INITIATIVE 2010 DIGNITY AND RIGHT TO HEALTH AWARDS - more details of the joints winners

The joint winners of the 2010 Dignity and Right to Health award are Dr Gisela Schneider from Germany and Dr Joseph, Kwong Jeung Yu from Taiwan.

Dr Gisela Schneider  has worked for many years in West Africa, East Africa and now more recently in Europe. Working in multiple settings she has been and continues to be a strong advocate and role model for many through her excellence in several fields of the HIV challenge, including clinical work, community engagement and mobilisation, and teaching. Dr Schneider is an exceptional person who has demonstrated an incarnational ministry in Gambia and Uganda and now continues to seek to bring Christian healing and compassion to people in many other countries through the work of Difaem, the German Medical Missionary Association. Gisela continues as a great role
model for all. Her work in the many fields of HIV medicine and community responses has been of the highest calibre.

Dr. Joseph, Kwong-Leung Yu has done excellent work in both his home country of Taiwan and also for many years in the nation of Malawi. He energetically worked at setting up a model of how to eliminate discrimination and stigmatization of HIV/AIDS in the public domain. He actively participated with PLWHA groups to encourage and ensure the enhancement of public awareness. Dr Yu is an exceptional person whose ministry is growing.  He now represents Kingdom values in many other countries as well as continuing to serve the people of Malawi as Director of the Rainbow clinic. He has established and strengthened a comprehensive multi-level program in an area of great need in Northern Malawi working closely with government and local church communities. A journal article on the challenges facing Malawi prisoners spoke to us of a Christian man with a great heart to better the lives of those who are marginalised and rejected by many.

It is a great honour and priviledge for the ICMDA to recognise and acknowledge the exceptionally inspiring service and witness of Drs Schneider and Yu to the glory of God the Father, Son and Holy Spirit.

We pray for God's presence to be ever with them both.

Previous Award winners

2006 - Dr Biangtung Langkham (India), 2007 - Prof Ruth Nduati (Kenya), 2008 - Dr Geoff Faster (Zimbabwe) and 2009 - Dr Stephen Watiti (Uganda).

Joint Winners of 2010 Dignity & Right to Health Award #WAD

After much discussion and prayerful reflection, the 2010 Dignity and Right to Health award of the ICMDA HIV Initiative is to be jointly awarded to Dr. Joseph, Kwong-Leung Yu of Taiwan who has worked for many years in Malawi and Dr. Gisela Schneider of Germany who has worked for twenty years in the Gambia and many years in Uganda.


Dr Gisela Schneider - Gisela has worked for many years in West Africa, East Africa and now more recently in Europe. She has worked in multiple settings and has been and continues as a strong advocate and role model for many with her excellence in several fields of the HIV challenge including clinical work, community engagement and mobilisation and teaching. Dr Schneider is an exceptional woman who has demonstrated an incarnational ministry in Gambia and Uganda and now continues to seek to bring Christian healing and compassion to people in many other countries through the work of Difaem, the German Medical Missionary Association. Gisela continues as a great role model for all. Her work in the many fields of HIV medicine and community responses has been of the highest calibre.

Dr. Joseph, Kwong-Leung Yu has done excellent work in both his home country of Taiwan and also for many years in the nation of Malawi. He strongly tried to set up an example of how to eliminate the discrimination and stigmatization of HIV/AIDS in the public. He actively participated with PLWHA groups to encourage and ensure the enhancement of public awareness. Dr Yu is an exceptional man who ministry is growing and he now represents Kingdom values in many other countries as well as continuing to serve the
people of Malawi. He has established and strengthened a comprehensive multi-level program in an area of great need in Northern Malawi working closely with government and local church communities. A journal article on the challenges facing Malawi prisoners spoke to me of a Christian man with a great heart to better the lives of those who are marginalised and rejected by many.

It is a great honour to have both Dr Yu and Dr Schneider join the ranks of earlier nominees and winners of the Dignity and Right to Health award of the ICMDA HIV Initiative.

Three nominated for the 2010 Dignity and Right to Health Award

Given to individuals and organisations for excellence, outstanding leadership and compassion in responding to the HIV/AIDS epidemic, the ICMDA HIV Initiative Dignity & Right to Health Award this year has three nominees:

1. Dr Gisela Schneider – nominated by Dr Vicky Lavy. Gisela has worked for many years in West Africa, East Africa and now more recently in Europe. She has worked in multiple settings and has been and continues as a strong advocate and role model for many with her excellence in several fields including clinical work and teaching.

Gisela’s work has been focused on developing community based responses that are integrated with government, church, hospital, training institutions, etc. Has an emphasis on building capacity by getting all stakeholders (e.g. churches, hospitals, families) to work to their strengths in addressing HIV.

2. Dr. Joseph, Kwong-Leung YU – nominated by Dr. Herng-Der Chern, M.D, Ph.D. This nominee has done excellent work in both his home country of Taiwan and also for many years in the nation of Malawi. "Dr. Yu has been working in Malawi for 5 years. He strongly tried to set up an example of how to eliminate the discrimination and stigmatization of HIV/AIDS in the public. He actively participated the need group with the enhancement of public awareness."

3. Dr .Geoff Foster (Zimbabwe) nominated by Dr S. W. Hynd – Geoff, a paediatrician, has an outstanding record as a clinician, researcher, writer and advocate for the rights of orphans in Zimbabwe and beyond.

Interviewing processes are continuing. The award winner will be announced prior to World AIDS Day, December 1 2010.

The 2009 winner Dr Stephen Watiti, Of Uganda, continues his important clinical work with the Mildmay group in Kampala, and his important work in media and in advocacy for the rights of HIV infected and effected people.

What is Distinctive about Faith Based Healthcare & Advocacy?

The following is just a brief summary of some discussions held in London yesterday by the Faith Working Group.

It was noted that working with the UK's Department for International Development (DFID) presented some singular challenges for Faith Based Organisations (FBOs) and Faith Communities (FCs), and in particular getting them to understand the distinctives within faith based responses to health needs such as HIV.


Two members of the group highlighted how internationally, through President Obama, WHO, the Partnership Unit of UNAIDS and others, faith has become a key issue in international health and development circles, but this has had relatively limited traction in the UK.  The difficulty is not just one of evidence of a tangible difference made by FBOs, it is also one of world view and culture – most donors are driven by managerial, input/output approaches to health and development, whilst most FCs and FBOs come from a different world view, that is usually more relational, community, behaviour/lifestyle and values oriented. As a consequence most FBOs either buy into the donors world view for the sake of funding (and run the risk of losing their distinctive faith dimension in the process, becoming indistinguishable from secular development agencies) or they bypass donors and strategic bodies, operating independently, but keeping their faith based distinctives.

If we are going to engage with DFID (which seems to be where the FWG could make a singular contribution - there already being much work on engagement between faith and other bodies being done elsewhere), then we need to enter into a dialogue with them, and explore with them the specific dimensions that faith brings to the table that are distinctive, both in approach, practice and impact.

In light of the Pope’s recent visit to the UK, and his speeches that challenged the churches in the UK to be more engaged with society, and challenging society to allow space for faith and belief in the public square, alongside the positive speech from David Cameron (and other voices within the coalition, such as Baroness Warsi) it would suggest that, in the UK at least now is the time to make such an engagement.

World AIDS Conference – Vienna
Those who had been in Vienna in August reported back.  Some encouraging advocacy with Pharma – encouraging more of the big drug companies to sign up to the Patent Pool, and some good networking opportunities.  The big issue seemed to be the increasing emphasis, from USAID and the Obama administration on health systems strengthening rather than AIDS as a unique focus, and how this was feeding through into wider strategy and funding priorities from other major donors.

The Ecumenical Pre-Conference was really multi-faith, only one day, and as a result far too broad, large and brief to be of much value.  African voices were not much heard (the focus seemed to be more on intravenous drug users , commercial sex workers and men who have sex with men), and there was an overall feeling that the whole conference is now so large that it is of very limited value for the vast majority of participants.
Question marks were being raised about the value of the 2012 Washington D.C Conference, although there were plans to restore the faith based pre-conference to three days. See earlier posts reporting back from various other faith groups at the Vienna Conference for some wider perspective

Faith Based Advocacy
In a wide ranging discussion on the theme, several key points were raised.

Faith leaders have a huge impact on behaviour, and FCs on the whole put an emphasis on ‘orthopraxis’ (right behaviour) as much as they do on ‘orthodoxy’ (right beliefs).  As a consequence, being able to talke to faith leaders in their own terms and own language to help them see the value they can bring to tackling HIV by promoting behaviour change can be highly effective and reaching a whole community.  And often those communities are ones that secular groups find it hard to access – e.g. Muslim women in rural areas.
Advocacy to governments and international bodies can only come from our engagement on the ground – seeing the issues ‘at the coal face’, and so being able to present real cases and real solutions gives us a very strong voice. But advocacy that just changes policy and not behaviour of individuals or practices within a community is of very limited value.

However, many FCs, FBOs and religious leaders are anxious about advocacy because it can seem political and confrontational, and in some cases, e.g. where a certain FC is a marginalised or persecuted minority, it could rightly be perceived as dangerous.  However, there are ways of addressing these concerns and going back into tradition, scripture and the spiritual dimension to address advocacy needs.

One story was recounted of getting a group of Ethiopian church leaders together to start to self identify needs in their communities and what they could do to address them.  Without prompting they identified female genital mutilation (FGM) as not only a problem to be addressed, but one that they as male church leaders had overlooked. This led to a spontaneous act of public repentance, a lengthy prayer meeting followed be discussions on actions that could be taken to change attitudes to FGM, and subsequently they have been active in working to end the practice in their communities ever since.  They could see the need, could see from scripture that this was one they needed to address and there was a leading of the Holy Spirit to change.  This is not the sort of advocacy a secular group would have felt comfortable or able to facilitate, but it was one that a Christian organisation was able to.

AHPN shared how they were now working with Christian and Muslim leaders of the African Diaspora in the UK to address HIV and other health issues amongst the African expatriate communities of Britain, and were already seeing the huge influence of these leaders in changing behaviour and attitudes.

It was agreed that these discussions were opening up some of the areas where the British faith communities and FBOs should start a dialogue with DFID and the British Government.