This Month in HIV: Top 10 HIV/AIDS Medical Stories of 2006
On to number four. This, again, involves clinical trials. I like clinical trials because I think they help us understand how to do things. But this is not a drug clinical trial, not even a treatment strategy clinical trial; it's a prevention clinical trial. This was looking at male circumcision.
There had been some data showing that men who were circumcised seemed to be less likely to acquire sexually transmitted diseases, including HIV. This has been noticed in many parts of the world. So to help understand whether or not [circumcision] can really work in preventing acquisition of HIV, three different studies done in Africa -- one done in South Africa, one done in Kenya, one done in Uganda -- randomized men who [were] HIV-negative to get circumcised or not, and just continue. [To read an abstract of the South Africa circumcision study, click here. To read more about the Ugandan and Kenyan studies, click here.]
Everyone got lots of counseling. Everyone was told to use condoms. Large numbers of men were enrolled. In all three studies, the same thing was found, and that was that men who got circumcised had a profound reduction in new HIV infections compared to men who remained uncircumcised. So this is just really, really, incredibly important. First, that you could even do a study where you randomized men to have their foreskin removed is notable. That three studies were able to do it, over thousands of patients, is completely just remarkable. That alone gets it on the list.
But all three studies found the same thing: [That circumcision greatly reduced rates of HIV infection]. In fact, the three studies were all halted early because of the differences that were seen between the two arms. Now, some caveats. One is: There were men who were circumcised who caught HIV. So it's not absolute protection. What we're talking about is a relative reduction.
Number two is that circumcision is not without problems. Now, in these three studies, [the operations] were done in state-of-the-art clinics, and it was done well, but real world application may be different. We certainly don't want to minimize the complications that can occur with any surgical procedure that might be done as a preventive measure, where there's not really another indication. Certainly, there can be complications. And there are a finite number of those complications. So I think those are two major things.
The third thing is that we really don't have data about how this would work here [in the U.S.]. But I think that, given the data we're seeing, and there are data that men who have sex with men in the United States who are circumcised seem also to be a little, little, little bit less likely to pick up HIV. Now, again, there are plenty of circumcised men who have sex with men in the United States and Europe who have HIV. It doesn't offer you great protection, but it might offer a little bit more protection.
"As someone I overheard said, 'We're not going to circumcise our way out of this epidemic,' but it will reduce the rate of new infections in some places."
I also think that the last thing about this is, there could be an adverse effect here, and it's not related to something happening with someone's penis; it's something that's not happening with someone's penis. That is, men who get circumcised, [may] have a false sense of security; and really, that would be a shame. You could lose completely the benefits offered by circumcision if condoms aren't used. So why get circumcised if you're going to use condoms all the time? Well, that could be a very valid question. As someone I overheard said, "We're not going to circumcise our way out of this epidemic," but it will reduce the rate of new infections in some places. If you're one of those people who got circumcised and didn't catch HIV, and you live to be an old man ... great. It worked for you.
Can you explain why circumcision is effective at reducing HIV transmission?
Why they have less risk? The mechanism? Well, I think the idea here is: What does the foreskin do? The foreskin creates a nice, warm, dark place in a part of the body that is exposed to sexually transmitted diseases. As such, it can harbor sexually transmitted diseases. [The explanation for this] also includes cells: Because cells are there [in the foreskin], because there's inflammation that can develop there. Not all men take care of their foreskins the same way, and not all men have the same type of foreskin. Not all men live in the same kind of conditions. So what you see is that there could be inflammatory cells there. Inflammatory cells are just the gates through which HIV can enter the body. There are T cells there, if there's any inflammation.
So I think that removing that foreskin creates an environment where it's a little bit less hospitable to the HIV. We've seen this with other sexually transmitted diseases. We know that this occurs.
What was the percentage that HIV infection was reduced?
About [a] 40 to 60 percent reduction, over a short term. Now, we don't have long-term data because these studies were stopped before they could complete them.
"The difference between [circumcision] and an AIDS vaccine is, this would be a horrible vaccine because the protection is just so spotty. Look, I read somewhere that maybe something like 60 percent of men in sub-Saharan Africa are already circumcised."
So right now, that's kind of the closest we've come to an AIDS vaccine, right?
Yes. The difference between this and an AIDS vaccine is, this would be a horrible vaccine because the protection is just so spotty. Look, I read somewhere that maybe something like 60 percent of men in sub-Saharan Africa are already circumcised. Widespread circumcision hasn't protected that continent, at all. So I think we have to take this all with a grain of salt. This is not going to be a major, major preventive measure. But it adds to the ones we have now.
As I point out in our article on TheBody.com: When you can count on your fingers, you can count with your ABC's what we're told works, as far as preventing HIV, it's nice to put up another finger and say, well, there's also circumcision. I wouldn't discount it as being something that can help some people, but it's certainly not going to be the equivalent, a surgical equivalent, of an HIV vaccine.
So now we're up to number five.
Number five is an interesting study, and I think it's also a somewhat misunderstood study. What this study tried to do was understand how much it costs to treat people with HIV during their lifetime in the United States. [To read an abstract of the cost-analysis study, click here.] What these investigators did -- and these [researchers] are all people who think a lot about quality of life and cost/benefit analysis; this is sort of a dream team of people who are known for doing this kind of work. What they did is, they created a computer model of a hypothetical cohort of individuals who are starting HIV therapy. With that computer model, they can adjust things, like starting T-cell count. If we start everyone in the clinic at 200 CD4 cell count, versus starting them at 350 CD4 cell count, versus starting them when they first get diagnosed, we could see how much things would change, how [much] things would cost. They dumped into this model data from a whole bunch of different sources -- from how much drugs cost, to how many times people get hospitalized (and for how long), and how much that costs -- all these different things.
They came up with some really interesting findings, based upon how they ran this model. One thing they found is that it costs a lot to treat HIV; and that's not a surprise to anyone. But what they found especially was that, as the CD4 cell count drops, the costs increase. The costs are really built in; as you get further and further in the progression of HIV, from caring for people in the hospital, and those inpatient appointments certainly count for a lot; and there [are] more frequent outpatient appointments. People who are doing better, people with higher CD4 cell counts, they're not in the hospital as much. They are also certainly not seeing people in the clinic as much. So, the clinical cost [is less].
In fact, the fraction that is made up by HIV therapy, as a segment of the total cost, starts to diminish as people's T-cell count drops. For people with a high CD4 cell count, therapy is the big-ticket item. For people with a low CD4 cell count, that's [the cost that has] got to get a little bit diluted by all the clinical care they're acquiring.
"Based upon their modeling, the lifetime cost of treating a person with HIV who starts at around 350 CD4 cells or less was almost $400,000."
So I think that was one thing. Based upon their modeling, the lifetime cost of treating a person with HIV who starts at around 350 CD4 cells or less was almost $400,000 -- and that's including discounts on HIV medicine that are taken into consideration. So overall, that was the cost. In fact, when you look at people who start HIV therapy right after infection, even though you're treating people longer, the cost goes down. That was because people just generally are doing better; they're not going to have any of these adverse consequences that are related to progression of HIV. There's further discounting as time goes on. So that was sort of an interesting finding. [To read more about the economics of HIV, click here.]
The other thing that came out of this study that I think got some attention -- maybe unintentionally, from the investigators' standpoint -- was that to understand how much it would cost to treat someone for the rest of their life, they had to kind of "guesstimate" how long someone with HIV, starting at the levels we start HIV therapy now, would live. Their computers spit out a number of about 24 years. Now, that 24 years was based upon this computer simulation, based upon all the data we have on how people do with the current batch of HIV medicine, This is how long we would expect someone to live. It doesn't say anything about what really can happen to any one individual starting today on HIV therapy.
So I think that it's not to be looked at as -- this is the best HIV therapy can do. It's a ballpark figure of what we could realistically expect someone starting therapy today, on average, to do ... how well they will do. There's all sorts of factors that could get played into that, including how old you are when you start therapy. Certainly, someone 70 years old starting therapy would have a different life expectancy than someone 25 starting therapy. It doesn't take into account new advances that could happen this next year, or within the next five years, [which] can change that completely.
I think a lot of people have centered in on that 24 years. On the other hand, the 24 years, I think, is not a bad number. I think it shows that we have made tremendous gains over the last several years of extending people's lives. So I think that this is an important article, because it helps us understand, policy-wise, that treating HIV sounds expensive, but compared to other chronic illnesses, it's not that bad, and that people are expected to live decades -- on the order of decades, not years.
But what do you think, Dr. Wohl? Do you think that people have a normal life expectancy if they're diagnosed with HIV in 2007?
"If people come in with a little bit higher CD4 cell count ... listen to most of what I say and take care of themselves, I tell them I expect them to get old and gray, that they can live, literally, for decades."
Of course, it all depends upon how people come in. But when I see someone who is not fantastically elderly, who comes in and does not have a CD4 cell count of 50, and [does not have] PCP pneumonia [pneumocystis carinii pneumonia], or cryptococcal meningitis, or any of these horrible infections people get when they have really advanced AIDS. If people come in with a little bit higher CD4 cell count, who basically can follow through, who can come to their clinic appointments, listen to most of what I say and take care of themselves, I tell them I expect them to get old and gray, that they can live, literally, for decades.
Even if you took [these data] literally [it's not bad.] I say to someone who's 40 years old and comes into the clinic, "Look. Over the next 25 years I expect you to do great. Not that you're going to explode at year 25, but that, relatively, we can expect you to do great. What do you think's going to happen in the next 25 years? We're definitely going to see advances in care. You're going to be around. My goal is to get you around until there's a cure. So your job is to not do crack cocaine. Your job is to come to clinic and take most of your medicines." That's the kind of conversations I have. Some people I see are already in their 60s or 70s. I do tell them, "This is not going to kill you." When I see the 25-year-olds [in my office], I say, "We're going to have to work together, because we want you to be alive for a long, long time. There's less room for you to mess up. Let's get you on therapy, good therapy. Let's keep you on it for years and years and years." Again, "let's add up the decades."
Great. So it's a very positive study.
I think it's a very positive study. It doesn't cost that much, and people are getting benefits. Duh. We need to start supporting HIV therapy for everybody.
Copyright © 2007 Body Health Resources Corporation. All rights reserved. Podcast disclaimer.
This article was provided by TheBody.com. It is a part of the publication This Month in HIV.
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