On November 8, Secretary of State Hillary Clinton gave a shocking (to me, anyway) speech at the National Institutes of Health at Bethesda, MD, before a packed house of politicians and scientists. Under the log-line of "Creating an AIDS-Free Generation," Clinton outlined a 3-point program by which HIV freedom would supposedly be won for the world - notably developing nations.
The speech went up on the State Department's webpage, so it represents official foreign policy. The log-line was instantly echoed by Eric Goosby and Mark Dybul, past and present coordinators of U.S. Global AIDS, who rushed into print in the Huffington Post with praise for the speech. Hillary's program also touched off a flurry among NGOs that had been distressed by years of government cutbacks on AIDS funding.
I found the speech "shocking" because Hillary made only passing mention of vaccines -- after all the hoo-rah over "promising" research that we've heard for years. The hoo-rah included assurances by President Clinton in 1996 that there'd be a vaccine in 10 years. Hillary did give a passing nod to the $1 billion spent on vaccine research so far.
But the fact is, her program seeks to expand same-old approaches that - in real life, not in the AIDS-industry rhetoric where so many people are stuck - delivers only partial progress. And the cost of what she's proposing will be astronomical.
Point #1 - Preventing Vertical Mother-Child Transmission (PMTCT)
In the spin-doctor language of AIDS, media and politicians shade their log-lines to give the impression that ARVs effectively prevent almost all babies from infection by their HIV+ mothers. A 9/26/2011 piece in the New York Times stated, "The medicines that prevent the transmission of HIV from mother to child are highly effective when they are used properly - that is, taken at the right time in gestation and in the right doses by both mother and newborn." In Africa, according to the spring 2011 Public Eye, a founding member of the Coalition on Violence against Women in Kenya echoed this mantra when she said, "Overwhelming evidence shows that transmission of HIV can be stopped by giving mothers the medicine Nevirapine before delivery."
But let's look at what the studies actually say, to see how ARV effectiveness in mother-baby treatment is often overstated by the media and industry apologists. In the original 1999 Uganda HIVNET study, evidence showed that nevirapine - in a single dose to mother and baby each - achieved a 42% reduction in transmission. In the next major study, done in eight African countries and published in AIDS in 2004, the authors confirmed that this simplest, least expensive treatment - mother and baby receiving the single dose - is 47% effective.
In other words, NVP treatment fails in more than 50 percent of mother/baby cases. The child for whom it failed faces a lifetime of ART, and often develops early drug resistance. As the New England Journal of Medicine pointed out last year, science has still not solved the problem of drug resistance on the PMTCT front.
The alternate route - a lengthy treatment of mother and baby that combines nevirapine with AZT - raised the effectiveness rate to 63-68% in the 2004 study. But that figure means that treatment still failed in 32-37% of the women - one third.
Unfortunately, this combo treatment is not only more lengthy, but more expensive. And it's prone to poor adherence, since women in developing countries often find their access to the drugs disrupted by countless social factors. Therefore, in our budget-busting time, this second approach will not be much used in developing countries.
Bottom line: Hillary's march towards a "generation of AIDS-free babies" will proceed only haltingly in the developing world, with around 50-percent failure in each round of treatment.
Point # 2 - Expanding ART Globally
This past spring brought a big media splash about the 2005 international NIAID study, HPtN 052, which ended four years ahead of schedule with a fanfare of claimed success. Early ARV treatment was given to serodiscordant adult couples from 13 countries. In one group, treatment started when the HIV+ partner still had a relatively healthy immune system (CD4 count between 350 and 550). In the other group, treatment was delayed till the infected partner's CD4 count sank below 350. The result, according to a NIAID report: "Earlier initiation of antirerovirals led to a 96% reduction in HIV transmission to the HIV-uninfected partner."
According to Goosby and Dybul in their Huffpost blurb, this study means that early ART treatment is "on par with a vaccine." They pronounced it an "extraordinarily successful tool for prevention."
Oh...I get it. Thanks to this study, ARVs can now be officially declared as the perfect and wholly adequate substitute for a vaccine. So, according to Hillary, we can plan on finding "AIDS freedom" for the world without the long-promised AIDS vaccine. All we need is more money.
Unfortunately, I doubt there is enough money in our borderline-bankrupt world to fund this international effort. Hillary is proposing treatment - for the rest of their lives, however long they live - of those estimated 33.3 million people all around the world who are living with HIV/AIDS. The arithmetic on this is staggering.
Because of ARVs, the AIDS industry has cozied into rhetoric that AIDS is now a "chronic, manageable" disease. As a result, its public positioning about cost has been adjusted with an eye to PR. In 2006, Medical Care reported on a study averring that the life expectancy of an American with AIDS has increased from 7 to 24 years, with a lifetime cost of treatment at around $600,000. But this figure is misleading - it didn't include management of side effects or treatment of opportunistic infections.
Here's what happened in real life, cost-wise, for a gay male friend of mine who recently died after 20 years of treatment. He battled KS, then anal cancer, and needed a colostomy, before finally succumbing to liver cancer. His surviving partner went over the records and told me: "Procedures, emergency room visits and medications before and after the colostomy alone ran approximately $2 million! If he had lived long enough for the liver transplant, costs would have soared to about $5 million over the next three years or so."
My surviving friend is still going through his partner's records, and promises to give me a bottom-line figure of how many millions of dollars the 20 years of treatment cost. It included the cost of Section 8 housing, since this man living with AIDS could no longer work and afford to pay for housing.
Out there in the developing world, the for-real lifetime treatment costs have a still darker hue. In Africa, the world's 2nd most populous region, many of those people living with "chronic, manageable" AIDS will live less long after treatment, because of all the other base-line health problems facing Africans, not to mention potential disruptions of their treatment by civil war or infrastructure breakdown.
It's true that pharma corporations are now discounting some drugs heavily, so an African's lifetime treatment costs will add up to less than before. But these costs, multiplied by human millions, still tot up to staggering amounts of money.
This article is part 1 of a series that started in the December 2011 A&U Magazine. In the next part, I will analyze point 3 of Hillary's speech and continue discussing the program's colossal cost impact.
Transcript of Hillary's speech
Nevirapine only partially effective:
"Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries," by Sweat, O'reilley, Schmid, Denison and De Zoysa,"
Huffington Post piece by Goosby/Dybul
NIAID report on HPtN 052 study