2010: A Reappraisal Reveals a Turning Point in the Pandemic
As an action-packed year for the HIV/AIDS community draws to a close, TheBody.com takes stock of 2010 in a new series of articles, "HIV/AIDS Year in Review: Looking Back on 2010 (and Ahead to 2011)." Read the entire series here.
A few weeks ago the friendly folks at Body Central asked if I would be interested in blogging about HIV/AIDS developments of 2010 from my unique perspective as a positively charged HIV physician specialist. The thought of a 2010 retrospective didn't immediately appeal to me, as there really weren't any major treatment breakthroughs this year. So I blogged about common condom conundrums instead.
However, sitting here at my favorite coffee shop with my steaming nonfat vanilla cappuccino in hand in a post-Christmas haze and discussing HIV/AIDS developments over the past year with my lawfully wedded spouse, fellow HIV specialist physician, fellow expert in TheBody.com's forums and partner in life, love and the pursuit of happiness, I've now come to realize that I may have been a bit too hasty in my initial assessment of what 2010 will mean when the history of HIV/AIDS is eventually written. In fact, I now believe 2010 may well be a pivotal year in the AIDS pandemic, despite the lack of major treatment breakthroughs! How can that be? Glad you asked. I'll make three quick points.
Point #1. On December 1, in commemoration of World AIDS Day, UNAIDS released its updated global epidemiology report. The encouraging statistics revealed that (1) new HIV infections fell by nearly 20 percent over the past decade and (2) the number of AIDS-related deaths dropped by nearly 20 percent during the past five years.
Point #2. 2010 will be remembered as the year that biomedical HIV prevention finally turned the proverbial corner, and it did so on multiple fronts.
This year at the XVIII International AIDS Conference in Vienna, Salim Abdool Karim reported results from the CAPRISA trial. The results prompted the usually dour conglomeration of HIV preventionistas in the audience to explode with triumphant applause, not unlike an arena filled with wildly dressed fans when Lady Gaga launches into a rousing rendition of "Bad Romance." Well OK, maybe that's a bit of a stretch, but really, the audience did indeed "go wild" based on stodgy scientific conference standards. The study reported that South African women who applied a vaginal microbicide gel containing one percent tenofovir before and after sex had a 39 percent lower risk of HIV infection compared to women using a placebo gel. The decreased risk of acquiring HIV improved to 54 percent for those women who used the microbicide as directed most often.
On first glance these results may seem somewhat modest; however, considering the past three decades of biomedical prevention research have produced almost nothing but frustration, this response is being hailed as a major breakthrough. Prior studies of other microbicide compounds showed no protective effect. Nonoxynol-9, one of the first microbicidal candidates, actually increased susceptibility to acquiring HIV! Other types of biomedical prevention therapies have demonstrated poor efficacy. Countless HIV vaccine candidates, for example, have failed at very early stages in development and/or testing. Merck's V520 vaccine was actually associated with an apparent increase in the risk of HIV infection in the STEP trial. (It was the Nonoxynol-9 of vaccines!) A combination vaccine trial in Thailand announced in 2009 with great anticipation failed to live up to the hype and initial fanfare. With three decades of disappointment as a preamble, you can see why the CAPRISA results were greeted with such enthusiasm. It has in essence opened the door wide to further research for an effective woman-controlled HIV-prevention method.
As with CAPRISA, a tsunami of ebullient enthusiasm has greeted the news that pre-exposure prophylaxis (PrEP) can significantly lower the likelihood of HIV infection. An international trial called iPrEx enrolled nearly 2,500 participants worldwide. At-risk gay and bisexual men who took Truvada (tenofovir plus emtricitabine) on a daily basis demonstrated a 44 percent lower risk of acquiring HIV compared to men who took placebo. The protective effect improved to a 73 percent lower risk for those with the best adherence.
The reason this is such a major breakthrough is that iPrEx has clearly demonstrated that PrEP is not just a plausible theoretical concept, but rather a verifiable reality. There is some evidence that our safer sex HIV-prevention campaigns for MSM (men who have sex with men) may have reached some sort of saturation level. It seems no matter how loud we yell or how good one's intentions are to play safe, self control tends to get lost after a few drinks or when winding up between the sheets with a potential Mr. Happily-Ever-After. Latex condoms, despite improvements in sensitivity, texture, flavor and ease of application, remain in their brightly colored foil wrappers far too often when two horned-up hotties decide to do the dance with no pants.
Many questions about PrEP remain: cost, access, side effects, adherence issues, etc. These will need to be addressed as we move forward with this and other biomedical prevention methods. However, there can be no doubt 2010 has been a breakthrough year, not for treatment, but for biomedical prevention. There is growing evidence that, as Bill Gates stated, "we cannot treat our way out of this epidemic." Consequently we must increasingly turn our attention to improved prevention and the holy grail of viral eradication/cure.
Point #3. A cure for HIV is now more scientifically feasible than ever before. 2010 saw a dramatic reinvigoration of the search for a cure. Researchers from governments, academia and the pharmaceutical industry have begun to combine forces and explore a variety of new approaches. Top on the list of potential cure strategies are (1) drugs that can flush out latent HIV from resting cells and (2) gene therapy to alter stem cells such that they produce T cells resistant to viral entry. I promise to delve deeper into these tantalizing topics in my next few blogs. Stay tuned! But for now my cappuccino has just been refilled and the vanilla-infused foam is overflowing. It reminds me that some folks are "cup half empty" types while others are "cup half full" types. I continue to be a "cup runneth over" type, just like my cappuccino. So despite the grim financial situation, the cringe-inducing results of the midterm elections in the U.S. and the lack of major treatment breakthroughs for HIV/AIDS during 2010, I remain extremely optimistic about the future.
The year 2010 showed us a decline in worldwide HIV/AIDS new infections and deaths. In addition, biomedical prevention efforts took giant steps forward with CAPRISA and iPrEx. And the search for a cure has been reinvigorated. All in all, 2010 may well ultimately be viewed as one of the key turning points in the AIDS pandemic. Thankfully, we are finally turning in the right direction.
Happy Healthy New Years to one and all.
Bob Frascino, M.D., is President and Founder of The Robert James Frascino AIDS Foundation. He is also an outspoken, popular expert in TheBody.com's "Ask the Experts" forums on safe sex and fatigue/anemia.