Tuesday, January 05, 2016

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
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.

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