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Saturday 12 November 2016

HIV - Prevention by clinician

Posted in: Health & HIV
By Jay Bennie - 3rd December 2013





The NZ AIDS Foundation has called the main international body with oversight of the global HIV/AIDS epidemics, amongst others, misguided and homophobic.

It has sharply criticised recent UNAIDS statements that have touted the end of the global HIV epidemic by 2030, pointing out that there is no evidence that its main strategy to achieve this goal, treatment as prevention, will work for gay and bi men. And, the NZAF points out, the rate of HIV infection amongst gay and bi communities is the one sub-epidemic still rising almost everywhere.

Dr Luiz Loures of UNAIDS
UNAIDS, a monitoring and information body which can advocate and assist but was not set up to directly fund HIV work, has historically been reluctant to publicly engage with the NZAF's criticisms, which have been voiced for almost two years. However, just over a week ago managed to speak with Doctor Luiz Loures, the Geneva-based Deputy Director, Programme, for UNAIDS. His first involvement with HIV was thirty years ago in his native Brazil.

In conversation Dr Loures exclusively uses the term "msm" to refer to men who have sex with men so we have retained that useage within his comments here. In transcribing his thickly-accented and Portugese language manner of speech we have occasionally inferred or clarified his choice of words.

We first asked Dr. Loures what priority UNAIDS itself gives preventing of the spread of HIV amongst men who have sex with men compared with heterosexual people.

"From an institutional point of view, and I am sure you have seen our statements and reports, the epidemic amongst MSM is the highest priority and there are reasons for that," he says. "It's not an issue of choice, it is driven primarily and basically by the epidemic itself. You see, [HIV is] the only truly global epidemic today. The way that I see it is that the epidemic amongst msm is increasing everywhere in the world... in the Americas, in Europe, in Asia, the middle East, Africa, everywhere. The increase is sufficient for UNAIDS to take the epidemic amongst msm at the highest level."

Loures immediately points out that the HIV epidemic has evolved over the years. "If you take a historical perspective of the epidemic, and I can tell you I saw my first AIDS case in 1982, it is no [longer] the initial epidemic, the epidemic we saw in the beginning. I was speaking a couple of weeks ago at the European Parliament in Brussels exactly on this issue, on the epidemic amongst MSM and discrimination... and I was telling them there is a 'legacy' issue."

He seems to move onto something of a charm offensive as he explains his sense of a 'legacy issue.'

"When I started dealing with AIDS, I saw what were among the first AIDS cases in the world. There were days that I could not leave the hospital because I could not count on my own colleagues on duty to take care of my own patients. And the only ones that showed up to give any kind of support to my own patients at this time were their peers. This was before HIV had been identified, much before. Nobody was taking care, only their peers. That's where the movement, the social movement that was the fundamental driver on AIDS, on our response to AIDS, was initiated to us... through this kind of peer support. This kind of community support, that was not only in this case supporting my own patients but was supporting millions of other patients.

"The point that I am trying to make when I speak of our organisations' legacy is that I have no doubt that we [have come] this far today responding to AIDS, including the epidemic in heterosexual people, because of the legacy of the social movement that was basically initiated by the gay movement in the 1980s. I see the epidemic among msm as a cross-country issue, the one epidemic that is growing everywhere in the world. But I have also the historical perspective. We do need to take care of these [people], there is no question... it is a moral obligation as well in many aspects."

The uncompromising claim that Loures made leading up to Sunday's World AIDS Day, announcing the end of the global HIV epidemic in just over twenty years, relegated the advice that there is no indication at all yet of the end of the epidemic for men who have sex with men to the lower reaches of the statements. Does it concern Loures that it was taken by the NZ AIDS Foundation that he was practically ignoring the epidemic amongst gay and bi men in his statements?

"There is [an apparent] major contradiction if you have been ignoring parts of my statements," he responds a little tartly. "But, as I said before, it is a priority for my organisation. But of course there are several aspects of when we talk about the end of the AIDS. Let's take this from the very positive [aspect], that one of the ways of seeing the response to AIDS [is] that we came so far in such a relatively short time. But if you had seen what I saw, what my generation saw, of this epidemic day after day, there [has been] a sea-change. By any parameter you like to take we are seeing sections going up, mainly in the most-infected countries - we are not speaking about msm here - and we are seeing [sections] going down. We have today more than ten million people under treatment, the majority of them in developing countries. The dying of the AIDS, the catastrophe that you saw in the beginning, in the countries that were most-affected... the industry that was growing [most] was the funeral industry. That was the reality of the AIDS before, [but] it is not the reality any more. We know more, science is moving forward. We are not there yet but we have better drugs, we have better technology for prevention. I can remember one time in 1996, the whole spending globally on AIDS was of $300 million dollars. Today it is estimated that we are spending more than $17 billion on the varying responses to AIDS."

Primarily gay- and bi-focused, the NZAF is increasingly seeing the global HIV prevention programmes as the metaphorical "bucket half empty." Loures clearly sees it as half full. "By many signs you see we have progress and this combination all together I think is allowing us today for the first time to say: 'Yes, it is possible to take this epidemic to the end.' There are some transmission routes that we are seeing now [which] are close to being eliminated, like the mother to child transmission is not happening in the developed world and in the developing world it is moving very quickly. There is no question that if you take it all together you can say: 'Yes, we are seeing the end in sight.'"

Just not for gay and bi men. "There is a major reason today that in some regions there are some populations [which] may be left behind. We see the end but we see the populations left behind and that is where we bring back the issue of the msm epidemic, where there is a clear association of discrimination. If you are [subject to] discrimination you are not going to be able to take [action]. There are limitations. For example, getting the preventive drugs to all parts of the world. They are not everywhere... in some parts like Eastern Europe there is a major, major limitation of lack of access to harm reduction products. We need to resolve that. Migrants is becoming a problem... as we have more people moving around the world the more there is of risk [through] migrants with HIV.

"When I speak of the end of the HIV/AIDS, Loures says, "I always qualify that it is the end... but there is one end that I think we may consider, and that is that we do not leave anybody behind. And the challenge today I don't think is so much on the science aspect, the challenge is on the discrimination side of things."

Speaking on the science side of things, which is one aspect the NZAF is taking Loures and UNAIDS to task on, what actual scientific evidence can he offer that treatment as prevention will work sufficiently well among men who have sex with men. Where is the evidence for that?

In response, Loures offers no evidence on the practical efficacy of using treatment-lowered viral load in individuals as a significant element of prevention strategy. Instead, he says, "I strongly believe that it will work but we need to put it into perspective, it is not a silver bullet. It is one of the tools that may help us to go a long way but it not a silver bullet, it will not work alone by itself. It needs to be combined with condom use and that is still the most effective way to prevent transmission. And there are other mechanisms, other technologies, to prevent HIV. But there is no question that it is an option today."

Loures says he travels to many places to talk to people about the effects of HIV/AIDS, which informs his view. "I am talking a lot to the representatives of the msm community and that was why I was so interested to talk to you. There is one aspect of this increasing epidemic among msm that I am particularly concerned is about, that the increase is more visible among young msm and that is not a question science can respond to. For some reason there is more complacence or perhaps they are less informed - which I don't think is the case - about the risk of the AIDS.

"The point that I am trying to make here is we must intensify our campaigns, the information, the programmes towards msm in terms of preventing sexual [transmission]. There is no question [regarding] using condoms. It's not that we don't know, we do know, but we are up against the fact that this epidemic will continue to increase among msm. The point here that I want to make is, is this treatment today for the msm community? They are the community that face the epidemic that is increasing almost alarmingly, [more than] any other community. Treatment [as prevention]should be put on the table as an option."

Perhaps it's his background as a medical clinician coming to the fore, but Loures begins to blur the subject in a way that interweaves treatment as prevention tool throughout a population base with treatment decisions made in the best and specific interests of a HIV-positive person's health. "I was in Sao Paulo just a few weeks ago," he says, "and I spoke to clients and to doctors that are on the front line as of now, to know what is happening today and there is no question that [treatment] should be part of the conversation. If a person is below CD4 500 [the CD4 count is a blood test result indicating the state of a person's HIV-infected immune system, not the level of HIV particles in a person's blood which can indicate how infectious they might be] I have no doubt there are full indications for treatment. As a doctor I have no doubt. But what we are discussing here is the ones that are over 500. In this case I think treatment should be put on the table as an option. And the decision on [whether] to treat or not should be a decision taken between a well-informed individual and their healthcare worker. But for it not to be put as [an] option today as we are up against an epidemic that is increasing, against a situation where risk is increasing, mainly for young msm men, I think would not be the right thing to do."

Here in New Zealand the NZAF continues to consistently push a very strong prevention mantra of "condoms every time," on the basis that opening up other options too much invites people to take more risks in terms of their sexual behaviour, and that relying on treatment as preventions to a significant degree relies on identifying enough HIV positive people and maintaining their low viral level so that they are less infectious. And it is well-documented that, wirh the best will in the world adherence to HIV drug regimes is not always good. Is it not creating a potential problem if we move away from the 'condoms every time' primary message?

"You have a very strong point. By no means should we drop the guard on the condom side. We may [now] have one more option, one more instrument, that may move us to a higher level of safety. We can reduce the risk if you combine [the two] but no way we should leave [condoms] behind. Condom promotion continues to be the most consistent [prevention approach], but there is an issue of adherence to condoms as well."

In New Zealand there are strong indications that a high proportion of gay and bi men use condoms always, or almost always, during sex with casual partners. But we have one of the best results in the world. In many other countries there is resistance to condom use, not just on an individual basis but on cultural levels as well.

"Yes," Loures agrees, "it is a complex situation altogether. I think there is no reason basically to have a 'yes or no' in terms of treating the msm community. [We need to consider] every option where the epidemic is ahead of us. It is very different if we were in a situation where today the epidemic among msm is all going down. Then I could say: 'Lets continue to do the same.' But it is not the case here. Therefore what we need in the mix is another method. This is my main worry today as somebody who has some responsibility vis a vis the AIDS epidemic globally.[What we are doing] so far is not taking us all the way. Therefore I think we should be putting treatments as prevention as an option to deal with this epidemic."

But, for the many places where condom culture is non-existent or failing, it is in retrospect notable that Loures, the medical man, does not seem to give any priority, in this discussion at least, to finding more effective ways to promote condom use to men who have sex with men.

His highlighting of "technology for prevention" also sticks in the mind. As does his phrase, in the context of prevention, "treating the msm community."  'Prevention capture by clinicians' is another aspect of the global response to the HIV epidemic, especially the sub-epidemic amongst men who have sex with men, that the NZAF, with its health promotion and behaviour modification stance, is more than unhappy with.

Tomorow, in the final part of this feature series, Loures reacts to criticisms that his own global organisation and others involved in HIV prevention, and which appear to be failing at risk gay and bi men around the world, are homophobic.

( regrets that, due to staff illness delaying our editing process, this article did not appear yesterday as expected.)

Jay Bennie - 3rd December 2013

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