Wednesday, November 23, 2011

Boosting Adherence to Antiretrovirals / UN AIDS reports AIDS epidemic may be reaching plateau

I already had HIV on the mind yesterday when I saw this news brief from the AMA (below). I had the privilege to hear a professor from Tufts speak about strategies to monitor and encourage adherence to antiretroviral therapy. There was an old thought that perhaps we shouldn't offer antiretrovirals to Africa because folks in resource limited settings wouldn't be able to adequately adhere to the regimen and would breed resistance. That's a scary proposition!

Well, the data flips that perspective upside down. Turns out, adherence studies in a half dozen or so cities in the US (think NYC, San Francisco, Hartford, and others) show Americans only reach 50-70% adherence rates while our counterparts in Africa frequently surpass 95%. Turns out they harness their social capital much more effectively and it boosts adherence. Imagine asking a friend or neighbor for money so you can get lifesaving drugs (or even so you could get the transportation needed to pick them up). To maintain the relationship, you're going to make darn sure you take those medications.

What about the issue of taking meds at the same time when you don't have a clock? You'd be amazed how creative folks can be - one gentleman had nearly perfect compliance over the course of a month (he timed his meds to a radio news broadcast at 7am and 7pm daily). He struggled a bit the next month, but that was because he fell in love and donated some pills to his HIV positive girlfriend who was running short on medications. So what turned out to be the best estimate of adherence? It was data from the pharmacy regarding prescription refills, this estimates the maximum possible adherence (and would miss the case of a patient sharing meds with others), but lined up very nicely with actual viral suppression rates.

In other news, this article below was published as part of the AMA Morning Rounds.

UN AIDS report suggests AIDS epidemic has plateaued. The New York Times (11/22, D5, McNeil, Subscription Publication) reports, "The world's AIDS epidemic has hit a plateau, with 2.7 million people becoming newly infected each year for the last five years, according to the annual report (pdf) released Monday by UNAIDS, the United Nations agency fighting the disease." The report also notes that "last year, 1.35 million got on treatment for the first time, meaning 200 people were newly infected for each 100 newly treated," compared with "two years ago, when 250 were infected for each 100 treated." However, "donor funds dropped about 10 percent last year as the worldwide economic crisis made some countries cut their donations." The report also compares a number of countries, pointing out that a large number of new cases are driven by "drug addicts, who are notoriously hard to reach, and also by groups like gay men and prostitutes who in conservative societies...have furtive, rapid sex -- a high-risk behavior."   

      The Washington Post (11/22, Brown) reports, "The biggest advances have occurred in sub-Saharan Africa, where a massive rollout of antiretroviral drugs, increasing acceptance of circumcision and changes in sexual behavior are driving new cases of infection to the lowest number in years." In contrast, "the big exception to the global trend is in the countries of the former Soviet Union and Central Asia, where there has been a 250 percent increase in people with HIV from 2001 to 2010.     

    Bloomberg News (11/22, Bennett) details, "A failure in Russia to implement harm-reduction programs such as offering drug users clean needles, or switching them to methadone tablets from heroin injections, is fueling the spread of the virus, said Paul De Lay, the deputy executive director of the Geneva-based agency." De Lay added that "five years ago they were really starting to see a turnaround," but now the progress has "pretty much fallen apart" and UNAIDS is pushing "for the surrounding countries not to follow the Russian Federation model."    

     The AP (11/22) reports that while "UNAIDS says it is working toward zero new HIV infections, zero discrimination and zero AIDS-related deaths," critics contend "that the body's aim of wiping out the disease is overly optimistic...considering there is no vaccine, millions remain untreated and donations have slumped amid the economic crisis."     

    CQ (11/22, Bristol, Subscription Publication) notes, "New infections reduced by 21 percent since they topped out in 1997. Deaths, which peaked in 2005, had also fallen by 21 percent by the end of last year. ... The report attributed progress in reducing the disease to changes in sexual behavior, especially among younger people who are reducing their number of sexual partners and using condoms more."         The UK's Telegraph (11/22) reports, "A significant expansion in access to treatment helped slash the number of Aids-related deaths in 2010, bringing the number of people living with HIV to a record 34 million," according to the United Nations. Also covering the story are Reuters (11/22, Kelland) and BBC News (11/22)"

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