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

2. 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?

3. Thabo Mbeki, President of South Africa, 1999-2008

4. South Africa has the most people HIV+ of any country

5. (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.
Peter Duesberg, UC Berkeley, HIV denialist
Refused money, meds, technical support, and other offers that might have reduced HIV.

6. The Response of the Science Community

8. 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."

9. The Continuing Battle Over Drug Prices

10. 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?

11. Where the Fights Are

12. 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.

13. 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

14. Who is Right?
Merck press release

15. Drug Resistance and Co-Infection

16. Drug Resistant HIV

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

18. Policy towards HIVDR

19. 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.

20. 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.

21. MDR-TB is widespread in Asia

22. Out of Africa

23. Spread of Anti-Retroviral Therapy

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

25. The Starting Point, 2016
= 44%

26. The Successes

27. The Failures

28. Key Failure Areas

29. An Example: MSM

30. HIV Prevalence among MSM varies greatly across countries

31. MSM Stigma

32. 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

33. AIDS Control Among MSM In Moscow

34. AIDS Control Among MSM in India

35. Legality of Same Sex Sexual Conduct

36. Accessing Safe Sex Technologies is Difficult

37. Is There Enough Money?

38. Money Needed

39. Impact of Funding