HIV Failures (and Challenges) QR24, Fall 2005, Lecture 2 HIV Failures (and Challenges)

Outline South Africa and AIDS denialism Pricing in Middle Income Countries Epidemiology: Drug Resistant HIV HIV-TB Co-infection Eastern Europe, the Middle East, North Africa Stigmatized groups Is there enough money?

Thabo Mbeki, President of South Africa, 1999-2008

South Africa has the most people HIV+ of any country

(In)Actions Mbeki denied that HIV was the cause of AIDS (Alternative theory: recreational and pharmaceutical drug use; HIV just hitches along) Including at International AIDS Conference in Durban, SA, 2000. https://www.youtube.com/watch?v=RCb9tdPIxoU Peter Duesberg, UC Berkeley, HIV denialist Refused money, meds, technical support, and other offers that might have reduced HIV.

The Response of the Science Community

The Denouement Mbeki is replaced as President by Kgalema Motlanthe. The new health minister declares: "The era of denialism is over completely in South Africa."

The Continuing Battle Over Drug Prices

Through the 2000s Pharma companies develop new medications, new formulations of medications, etc. Who should pay what? All agree that the poorest countries should get the drugs at cost. All agree that rich countries should pay more. What about middle income countries?

Where the Fights Are

Example: Thailand 2006: Thailand threatens a ‘compulsory license’ for Merck’s efavirenz. Ultimately, Merck agrees to lower price to generic level 2007: Thailand issues a compulsory license for Kaletra (a protease inhibitor) made by Abbott. Abbott responds by withdrawing registration of seven different drugs from Thailand. Negotiations lead to lower prices. 2007: Thailand threatens compulsory licensing for cancer and heart disease drugs.

Example: Brazil 2007: Brazil battles with Merck over the price of efavirenz. List price = $1.57 per pill Merck offered = $1.10 per pill Brazil wanted price offered to Thailand = $0.65 per pill Compulsory license by Brazil

Who is Right? Merck press release

Drug Resistance and Co-Infection

Drug Resistant HIV

Impact of Drug Resistance Second line treatments cost more May result in a resurgence in HIV.

Policy towards HIVDR

HIV-TB Coinfection HIV weakens the immune system. Makes people more likely to succumb to other infections. One of the most important is tuberculosis. TB lodges latently in the lungs before becoming active/infective TB mortality rate (untreated) is ~50% HIV increases this probability.

TB mutates rapidly, including drug-resistant strains. Multi-drug resistant TB (MDR-TB) is resistant to the two most common TB medications [isoniazid and rifampin] 4% of new cases, 21% of repeat cases Mortality rate ~ 65% Extensive Drug Resistant TB (EDR-TB), resistant to second line medications as well. Mortality rate ~ 80% Treatment regimen is more complex, although not unduly so.

MDR-TB is widespread in Asia

Out of Africa

Spread of Anti-Retroviral Therapy

Spread of Anti-Retroviral Therapy LA&C SSA World SA ME&NA

The Starting Point, 2016 = 44%

The Successes

The Failures

Key Failure Areas

An Example: MSM

HIV Prevalence among MSM varies greatly across countries

MSM Stigma

Russia 2013 law punishes punished the promotion of ‘non-traditional sexual relations’ to minors. Neither same sex marriage nor civil union of same sex couples is allowed. Authorities in Chechnya arrest and torture gay men. Public opinion is extremely anti-gay: 74% of Russians said homosexuality should not be accepted by society; 16% who said it should be accepted

AIDS Control Among MSM In Moscow

AIDS Control Among MSM in India

Legality of Same Sex Sexual Conduct

Accessing Safe Sex Technologies is Difficult

Is There Enough Money?

Money Needed

Impact of Funding