Search for a Cure- Ending the Epidemic

Reasons For Hope (RFH)

is Search For A Cure's national HIV treatment news series.

RFH covers the latest in developing therapies for treating HIV/AIDS.

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Why We Should All be in a Clinical Trial

It is hard to get people to join a study of new medicines nowadays. This is mostly because people think the therapies we have are good enough. It's not true. HIV medicines fail some people. And they are too expensive for most of the world to use.

The medicines we have are not a cure, are a lifelong financial burden and have lots of side effects. The only way to see if new therapies work is to test them on people with HIV. The only way to see if a vaccine will work is to test it on people without HIV. If we want the day to come that HIV is a thing of the past the most important thing we can all do is find a study that needs us and join it.

ending the epidemic

It is time to end the AIDS epidemic in the United States.It is a realistic goal.Some facts from official sources:

In San Francisco, one out of every four gay men is infected with HIV.
The gay population of San Francisco has gone up by 25% during the past ten years.
The total number of people with HIV infection has also gone up as people live longer using antiviral drugs that stave off disease progression.

Given these facts, anyone would predict with good reason that the number of new infections would go steadily up as both the number of people carrying HIV and the number of people likely to be exposed increase.

They would be wrong.

For the first time since the epidemic began, the HIV transmission rate in San Francisco went down -it is 20% lower than it was in 2001.

Many scientists and activists have offered explanations for this unexpected drop in transmissions. Perhaps it is because gay men are starting to seek out partners that have the same HIV status (called sero-sorting) thus engaging in what amounts to a kind of voluntary quarantine. Perhaps it is because half of infected men in San Francisco are taking antiretroviral drugs that dramatically reduce the amount of virus in the body. It probably makes them much less infectious.

Whatever the reason, it is important to millions of people at risk around the world to figure out why it is happening and duplicate it everywhere. The data from San Francisco shows we have the ability to end this epidemic. With tools that already exist.

The work of several scientists shows that reducing transmission by a relatively small amount could end the epidemic. Dr. Sally Blower of the Department of Biomathematics and the AIDS Institute at the David Geffen School of Medicine at UCLA developed models of the impact of imperfect vaccines on the HIV and other epidemics. ( See: www.semel.ucla.edu/biomedicalmodeling/index.asp)

Although these models focus on ending epidemics using vaccines, the same models would apply to anything that reduces HIV transmission.

These models show that vaccines that are nowhere near perfect (or any prevention method that reduces transmission but is not perfect) might still end an epidemic. This is because to end an epidemic you must reduce the rate of transmission below one new infection per infected person over the life of the person (make the "reproductive rate" less than 1), not protect everyone from being infected. When you look at the levels of risk for each type of act that could lead to an HIV transmission, you quickly see that reducing the probabilities by a modest amount would achieve rates low enough to end the HIV epidemic, that is below one new infection per infected person over the infected person's lifetime.

One study of HIV transmission rates from Seattle showed the following chances of transmitting HIV:

Action (Predicted transmission per 100 acts)

Blood Transfusion (90)
Needle Sharing (0.67)
Receptive anal sex (0.5)
Needle stick (0.3)
Receptive vaginal sex (0.1)
Blood to mucous membranes (0.09)
Insertive anal sex (0.06)
Insertive vaginal sex (0.05)
Performing oral sex on penis (0.01)
Insertive oral sex (0.005)

These figures are available here.

Numbers like these give credence to the idea that modest decreases in the odds of transmission could lead to the epidemic burning out.

Although we do not have a vaccine, the modest reduction in transmission necessary to end the epidemic leads us to hope that improved methods of prevention might do as well as a modest vaccine in reducing transmission.

Responding to the growing belief that prevention can be improved, states and cities have begun to use new ideas scientists have developed about HIV transmission during the past decade to upgrade prevention efforts.

For example, it is clear from studies conducted over long periods of time, like the Rakai study of Dr. Thomas Paquin, that the lower the viral load (a measure of the amount of virus in the body) the lower the chance an infected person will transmit HIV to a partner.

This is a powerful indication that using antiretrovirals may reduce infectiousness.

HIV testing (which in and of itself probably reduces transmission as it lowers risky behavior) and intervening with antiretrovirals may well be ways to lower transmission rates. It is known that the amount of virus an infected person has is by far the highest during the first few months after infection. It is estimated that 40% of all transmissions occur when the infecting party has a lot of virus soon after getting infected. For this reason, finding out status as soon after exposure as possible becomes a critical part of reducing transmission.

Finding and treating people immediately after infection serves a critical public health purpose as it lowers the amount of virus and therefore infectiousness at exactly the time people with HIV are most likely to transmit.

There is reason to believe this policy would be best for the person who is infected as it may reduce the amount of damage done by HIV in the early weeks after infection, before the body's defenses have a chance to control the amount of virus.

In 2002, North Carolina became the first state to use RNA tests for individuals who want to know their HIV status, a test which shows HIV before the 'antibody' tests are able to. North Carolina now uses both antibody and RNA testing to identify people who have been recently infected, before their bodies have produced antibody. This is when people are most infectious. Intervening early and using antivirals to get down the amount of virus, making people much less infectious, is a good public health policy. But it is happening in very few places. Recently, the cities of Rochester, N.Y., Seattle, San Francisco and Los Angeles have started using such tests. Florida and Colorado are planning to do so as well.

This summer Baltimore has begun to use a test which can tell if you have been infected as soon as one week after being exposed.

Systematic testing and treatment of high risk groups may lead to the best healthcare for those infected with HIV and along with other methods may help slow down transmission enough to end the epidemic.

In addition post exposure prophylaxis (treatment immediately after an exposure) has been shown to be effective at reducing infections in health care workers for many years and is now being tested on high risk groups at many places, such as the Fenway Community Health Center in Boston.

Also, Pre-exposure prophylaxis is being tested in several countries including the U.S.A. at several sites and may be a new tool to reduce transmissions.

For many years now, in spite of increases across the country in the number of people infected with HIV, the rate of new infections has been stable at approximately 40,000 per year. It is clear that the combination of testing, treatment and serosorting is holding down the number of new transmissions. To get that rate down further will take systematic implementation of the new tools that science has developed while continuing and broadening the existing efforts of safer sex and clean needles.

Massachusetts has become the most recent state to push for the sale of over the counter clean needles.

Leaving aside the human toll in suffering from HIV infection, the financial impact of a person getting infected is serious. According to B.R. Shackman, PhD, of Weil Medical College of Cornell University in a study published in 2005, Medical treatment for those 40,000 new cases will cost at very least, 15 billion dollars over the lifetime of the newly infected that the government, individuals, and insurance will have to come up with.

It is economically important to find a way to reduce the number of new cases of HIV.

(see http://www.aegis.org/conferences/IASHIVPT/2005/WePe12-2C07.html)

Finally, removing public policy disincentives to testing, such as laws which make those who know their status criminally liable for spreading HIV and the lack of available medicines in several states for many people, need to be public health goals.

We need to get our government focused on ending the epidemic.

It will save us lives, unnecessary pain, reduce medical costs and serve as an example to the world of how to put an end to this disease.

David Scondras is the founder and president of Search For A Cure.

Scondras developed the nationally-recognized HIV treatment series, Reasons for Hope .

All articles in the series are reviewed by expert HIV doctors & scientists as well as an HIV positive & negative focus group to ensure both accuracy and understandability. This article was reviewed by Dr. Al DeMaria, Chief Medical Officer of the Massachusetts Department of Public Health.

If you have any questions or would like to receive the Reasons for Hope series contact Search For A Cure at 617-945-5350 or e-mail at hope@sfac.org . Please visit our web site at www.searchforacure.org

Search For a Cure is a not for profit organization providing education, promoting access & advocating the basic human right to safe and effective treatment for all people living with HIV/AIDS.