Two notes on HIV/AIDS in 2018

Early on the evening of the 1st of December in Toronto, on World AIDS Day, I stopped by the AIDS Memorial. Fresh red and white carnations were woven among the panels as citylight gleamed in the background.



Many of the assembly of links I posted this evening over at my personal blog relating to World AIDS Day dealt with how it was being remembered. Others dealt with successful approaches to the epidemic, to the growing recognition that people being successfully treated cannot transmit HIV to other partners and to public-health approaches like that of Demetre Daskalakis in New York City which destigmatize HIV and make it manageable in a social sense as well as in a medical sense. Still others deal with how, in Russia, prevailing social conservatism is contributing to an accelerated spread of HIV; the Russian Demographics Blog noted the alarming shape of the HIV epidemic in Europe, with increasing success in the European Union being more than counterbalanced by an expansion of the epidemic in Russia.

As for HIV and AIDS, my thinking on this pandemic is dominated by two approaches.

1. As was made clear to me by Jacques Pepin's The Origins of AIDS, which not just traced the modern pandemic to a zoonosis in the interior of central Africa but outlined how a chance configuration of historical events led not only to the HIV pandemic but to the particular shape of the pandemic, the extent to which global catastrophes can be created by chance occurrences is appalling. What catastrophes, epidemiological or otherwise, have been unleashed on an unknowing world now? There may be good sense to the precautionary principle.

2. I remain impressed by the fact, realized by me in a 2016 visit to the AIDS Memorial, that biomedical intervention of a sort that would have been science-fictional in the 1980s can successfully control even HIV. What explanations--what explanations, more, that are not excuses--can there be for this pandemic's survival? If, as an early observer of HIV and AIDS noted, the epidemic immediately showed up the weak points in public health at every level, it still does this now.

On the Toronto AIDS Memorial and the impact of HIV antiretrovirals in the mid-1990s

I was in the area and it seemed apropos after the Orlando shooting, so I went off to visit Toronto's AIDS Memorial, in Church and Wellesley's Barbara Hall Park, before I went to work Monday afternoon. It is simple enough, pillars almost two metres high each with six inscribed metal plates of the names of the dead, organized chronologically by the year of their death, in a peaceful garden. It is a solemn place, but lovely for all that.

I've visited the memorial before. I even shared a picture of it last year, looking at the memorial pillars from the outside as framed by the roses. I had not taken a picture of the memorial from the inside, the pillars with the plaques of inscribed names--so many names--arcing away into the distance.



There is actually quite a lot of information you could surmise about the epidemic from the information on the plates. In the first years of the 1980s the plates are almost empty, one being more than enough for a year's dead. Later, they spill over into multiple plates. Still later, around 1990, the plates shift to a smaller type, as the surging numbers of people infected when HIV began its explosive spread in the early 1980s progressed to AIDS.

In the mid-1990s, the impact of effective antiretroviral therapy, much more effective than the easily blunted AZT monotherapy, becomes evident. It is on the 1996-1998 pillar this is most visible. The year 1995 took up most of the previous pillar, but 1996 took up a mere half, 1997 two plates, and 1998 only one. Later plates and later years revert to the low density of names of the mid-1980s, this time with the smaller font. (The 1999 and 2000 plates on the next pillar are visible to the left. Later years' plates have fewer names still, reverting to the early 1980s' larger font, as HIV infection becomes manageable.)

Anti-retrovirals worked. They continue to work, and in ways that might not have been imagined by the originators of modern anti-retroviral therapy, treating and even preventing HIV infection. Toronto's AIDS Memorial, and like memorials in other cities around the world, serve as effective partial records both of a terrible medical/human tragedy and how, if too late, this tragedy began to be ended. It's still too far away from ending in some parts of the world, but there is hope. What better testimony is there to this than the pillars of the AIDS Memorial which remain unscarred by plaques?

A note on public health, or, how you get what you pay for

Late last month, I blogged about PrEP, an acronym for "pre-exposure prophylaxis", as Wikipedia puts it "the use of prescription drugs by people who do not have HIV/AIDS as a strategy for the prevention of HIV/AIDS". When taken with sufficient frequency, the drug in question--in most studies, either tenofovir or the tenofovir/emtricitabine combination TruvadaSouth Africa and Thailand suggest that PrEP can be an effective anti-HIV strategy in middle-income countries as well.

PrEP is not the only transformative event in the treatment of the pandemic The latest anti-retroviral treatments are not only keeping the HIV-positive in good health, they are radically reducing the chances of further infection, via the strategy of TaSP (treatment as prevention). One thing widely reported in the media with varying levels of incredulity after Charlie Sheen's self-outing as HIV-positive, in Vox and Gawker and MacLean's and New York Magazine, is that Sheen has undetectable levels of the virus in his system and cannot infect people. This was not just Sheen talking: This is the actual science. Multiple research projects, including the ongoing PARTNER study, have so far concluded that the chances someone HIV-undetectable could transmit HIV on to someone HIV-negative are trivial. The PARTNER study has not yet found a single instance of such a transmission happening, not with tens of thousands of sex acts in hundreds of couples in two years. TaSP, treatment as prevention, also works. The approach of systematic testing and universal treatment of HIV, pioneered in Canada in British Columbia by Dr. Julio Montaner, can break the back of the epidemic. Saving people's lives also slows down the spread of HIV radically.

These successes raise an important question. Between PrEP and TaSP, not only is it possible for people infected with HIV to lead normal lifespans--indeed, some recent studies suggest that the sustained engagement with medical systems can give HIV-positive people longer life expectancies tan their HIV-negative peers, their HIV becoming a manageable
Journalist Laurie Garrett's 1995 The Coming Plague remains as relevant a book now as it was when it was published two decades ago. In that book, she made the point that the world was woefully unprepared for pandemics, that sustained underinvestment in public health and medical systems made it very difficult for increasingly fragile states to control infectious diseases within their frontiers. Governments, as she observed caustically in country after country, with disease after disease, simply seemed to have other priorities. The result was the risk of catastrophe. PrEP and TaSP may be effective strategies, but what does it matter if governments opt not to make the investments necessary? The United States is the country that developed PrEP and TaSP, and happily these strategies are becoming increasingly widely adopted in different at-risk communities which have access to them. PrEP and TaSP, though, require significant investments, in medication and in ongoing medical surveillance. Those communities which cannot access these investments are suffering horrifically: a recent Al Jazeera item suggests that HIV is spreading among black men who have sex with men in Atlanta at rates rarely seen in the United States since the 1980s. Similar stories can be told elsewhere in the world, only the details varying.

People elect governments, governments make choices, and too often these governments don't bother trying to deal with significant public health problems. The results, when crises erupt, can be catastrophic. I remain thankful that the West African Ebola epidemic has been fought back, though I wonder how many lives, how much wealth, how much potential could have been saved had the concerned governments and organizations behaved prudently. False economies are, by definition, false.