Wednesday, 24 November 2010

AIDS world rewired

The announcement Tuesday that pre-sex pills probably block HIV infection has the AIDS world, of which I am a part, in a second tizzy. The first one occurred in July at the big biennial AIDS powwow in Austria, and the implications of this double revelation are myriad and not yet entirely clear.

I unscientifically call them ‘pre-sex pills’ for clarity’s sake, but that’s in essence what they are: you ingest a low dose of the same medication that people who are already HIV-infected have to take, and voila, the nasty little virus doesn’t stick no matter kind of pelvic partnership you are down with (the study, called iPrEx enrolled gay men, mostly in Peru and Ecuador).

There are 8 million caveats for specialists to scratch their armpits over, but the operative concept is exactly the same as that shown to work in the South African vaginal microbicide study unveiled in Vienna this summer. In that case, women inserted a gel laced with an AIDS medication before and after having sex, and that also brought the anticipated number of new HIV infections way down.

The problem, as always, is human behavior. In both cases, even under the optimum conditions provided by research environments, an enormous percentage of study participants simply didn’t use the products as directed and obtained a correspondingly lower level of protection. This should surprise no one familiar with the tribulations involved in convincing people highly at risk for infection to use condoms. One would think that something as easy as popping a pill would generate greater adherence to the protocol, but it didn’t.

On the other hand, if people were not predictably non-compliant with life-saving advice, none of these research studies could ever obtain evidence. After all, a certain number of people have to engage in unprotected sex to produce the minimum numbers necessary for comparison’s sake. It’s a paradox of the research world that while vigilant protection of the welfare of human subjects is strictly enforced, the underlying assumption of any of these trials is that some people will take the risks you’re telling them to avoid so that the exposure arm and the placebo arm will produce measurable differences. If they don’t, the whole exercise is a waste of time.

That generates further complication because now that the pre-sex pill and gel techniques look awfully promising, how does one proceed with research at all? Some people argue that enrolling people NOW in placebo trials, given the apparent efficacy of the pre-exposure prophylaxis approach, is unethical. Others counter that the test results aren’t strong enough and that further confirmation is necessary before anyone can confidently recommend vaginal gels, rectal microbicides or pre-whoopy pill-popping.

Furthermore, any introduction of a new technique might also weaken the already unsteady condom-use practices of a large swath of the population. We might push people into an uncertain alternative causing them to ditch a proven, albeit uncomfortable, safety device, thus increasing rather than lowering their risk. How ethical is that?

The ethics and prevention debates, important as they are, remind me that such discussions, now carried on in remote, academic circles like mine, were once the province of whole communities. Gay men especially but lots of other people too once sat around thinking of what to do about the dangers out there and how to obtain sexual satisfaction despite them. That’s pretty much dead, from what I can tell.

I saw my doctor yesterday for the annual poke-and-prod session, and he remains indignant about the new cases of HIV infection he sees regularly in his practice. I have the feeling that he isn’t shy about telling patients what he thinks they should do, and it’s good that he raises the issues that many doctors would rather avoid.

But one thing I have learned about people’s sexual and other health-related behavior is that they hate to hear lectures about it, even—and especially—when the advice provided is crucial to their well-being. We’re a long way from figuring out how to resuscitate the kinds of horizontal, friend-to-friend, or barstool-to-barstool conversations that enabled the reimagining of sexual habits and practices that occurred in the 1980s.

The furiously reactionary opposition to that conversation raised by the Catholic and evangelical right was successful in driving it underground and crushing it. No lame, latecomer reversal from a pope is going to undo that damage.

[update P.S.] Here is what candidate Barack Obama said about AIDS in 2007:

‘I'll expand the President's Emergency Plan for AIDS Relief by $1 billion a year in new money over the next five years so we can reach more people’.

Instead, the Obama Administration has flat-lined funding and allowed 4,000 people in the U.S. to be forced onto AIDS drugs waiting lists. I know, I know, there was an economic crisis and a huge deficit. But that did not stop O from pandering to the Republicans he had just crushed electorally by offering them billion-dollar tax giveaways to attract a vote or two here and there--which he never got anyway.

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