The HIV viral load blog

A Taxi Ride in Lusaka

I don’t know about you, but I love talking to taxi drivers. More often than not they have an opinion and are willing to share it. They are a wealth of local knowledge, invaluable to a constantly inquisitive traveler like me. 

On one trip in Lusaka I was chatting to Chris, a local taxi driver. He was taking me from my hotel to the Swedish Embassy a short drive away. After the usual discussion about the fare, conversation turned rapidly to football. He gave the usual nonstop hysterical laughing fit at the suggestion QPR were obviously the greatest football team in the world and we soon settled down to further discussion about family and work. 

Once he knew I worked with HIV, he told me of family members who had passed away and the devastation the disease was causing. Now I know this will seem rude, but I always make a point of asking whether the taxi driver has had an HIV test or not and in Chris’s case it was no different. His answer was the same one every taxi driver I have ever spoken to in Africa has given. 

NO. 

The reasoning is this: “Since you cannot provide treatment for me, there is no point in me taking the test since I am going to die in a few years anyway. If I take the test and I am positive, I will lose my job, my friends and possibly my family, and I will die a lonely poor man in a few years. However, if I don’t take the test, then I will not know, I will keep my job, my friends and my family, and will still die in a few years but not as lonely and not as poor.” Of course I always ask the question: “Aren’t you scared of spreading the disease?” Chris’s response was typical – a shrug of the shoulders and a change of conversation back to football.

Thoughts on the International AIDS Conference in Mexico

I have just returned from the XVII International AIDS Conference. I always feel very optimistic after attending this event and proud to be working in the HIV field. I suppose that’s how these events are supposed to make you feel. This meeting is held every two years. The first was held in 1985. Not only is it the biggest AIDS conference in the world, but the biggest conference on a global health issue. At each conference I am overwhelmed at the amount of energy, enthusiasm and resources being focused on this disease. And every year I see the world’s resolve and commitment increasing. The number of participants in Mexico totaled 25,000 - the biggest yet. I noticed a couple of interesting developments at this year’s event.

First is a subtle shift I’ve noticed over the past few years. The meeting started as primarily a platform for doctors and scientists to share research and clinical findings. Today, that is no longer the case. In fact, there were relatively few scientific breakthroughs making headlines from the event. The meeting seems to have evolved into a platform to draw global attention to the pandemic and to the various players who are working on the problem. This year the networking and publicity aspects seem to have eclipsed the scientific aspects. And that’s OK. We have the lower-key IAS Conference on HIV Pathogenesis, Treatment and Prevention (the second biggest gathering of HIV experts) as the major platform for announcing breakthroughs in research and pooling scientific knowledge. With the level of complexity of the HIV problem, I would say both conferences serve vital purposes in the effort to overcome this disease.

Another change I noticed at this year’s conference was an increased focus on the role of diagnostics in managing HIV across the developing world. This is a natural and very welcome development arising from the increased availability of ARVs across these regions. In 2007, the efforts of organizations around the world put one million more people in the developing world on ARVs, bringing the total up to three million. With the greater prevalence of ARVs has come an increased awareness of how important monitoring is if those drugs are to do the most good for patients. Specifically, this underscores the need for a viral load testing platform, like our RT-platform, that can provide the greatest access to patients in the developing world and beyond. These sentiments were articulated by several speakers and presenters at the conference, most notably UNAIDS Executive Director Peter Piot and President Bill Clinton. 

During one of the sessions, Peter Piot stressed the importance of proper monitoring as a vital component of success in managing HIV. President Bill Clinton also underscored this when he told of how things are changing in his foundation from a focus on supplying drugs, to expanding into providing proper diagnostics. In a keynote address he stated, “When we started our work six years ago, we focused on lowering the cost of drugs and tests needed to be in treatment…and over the years we have expanded our work to include a wider range of IRBs in diagnostics.”

The Burnet Institute, who has done so much great work in the battle against HIV, presented a poster on ExaVir Load. The Institute of Human Virology in Baltimore, Maryland added four posters of their own where ExaVir Load was used to gather viral load data. Inside our own booth, we could sense a major shift this year with more people aware of the importance of proper monitoring. We had more visitors coming by and asking us about our assay than ever before.

We have many challenges before us, but I left Mexico with a feeling that the world’s AIDS community is making progress and moving in the right direction.

To tell or not to tell?

SWISS STUDY CREATES CONTROVERSY AT AIDS 2008 IN MEXICO.
Greetings from Mexico City. One of the hottest topics  here at the International AIDS Conference is how to handle the findings of a study published in Bulletin of Swiss Medicine (Bulletin des médecins suisses) that claims, "HIV-positive individuals on effective antiretroviral therapy and without sexually transmitted infections (STIs) are sexually non-infectious.” (quoted from AidsMap)

Some experts are saying we shouldn’t talk about this to HIV patients because they will take it the wrong way and engage in riskier behavior. It is also argued that in places where access to viral load monitoring is limited or non-existent, they can’t consistently track whether or not patients have undetectable viral loads anyway, so the information is of no positive use to them. These are, admittedly, fairly compelling arguments for keeping these results quiet.

But I see three problems with that advice:

1. Patients have the right to access
Ethically, the idea of the medical community conspiring to censor legitimate scientific research because we decide people can’t handle the truth seems like a flawed idea and a dangerous precedent to set. I think all people, and particularly those infected with HIV, are entitled to full access to all the information we have on the disease.

2. No one can keep this information quiet
The genie is already out of the bottle. The fact that you are reading about this now on the Internet is proof of that.  Beyond that, the topic is being heavily debated at the world’s biggest HIV conference.  The information is published and already spreading around the globe. Nothing I know of can stop that.

3. If the findings are not delivered clearly it could misinform
The results of this study are highly prone to misinterpretation. For me this is not a justification to keep it quiet. It is all the more reason to flood the market with information to keep the findings in context.  With regard to resource-limited settings, the overwhelming majority of HIV-infected individuals have no access to their viral load or STI status to even know if they meet the criteria specified in the report.

Do I feel people should be encouraged to have unprotected sex? No. Definitely not. Given the consequences of the virus, the low risk reported by the Swiss is still something that needs to be treated seriously. Even if the statistical probability of being struck by lightning is low, I’d still discourage anyone from standing in a field with a metal rod during a thunder storm. 

As for the resource-limited setting (accounting for most of the world’s HIV-infected population) the point made in the study is mute because so few people have the level of care required to meet the criteria specified to be in the low risk category. And lets face it, the study could simply be wrong.  It wouldn’t be the first time a well-conducted study was disproved by further investigation. 

For me the issue here is not “Whether we should keep these findings from the people?” The only issue is how can we best manage the impact of this information on the population. And that means being proactive and getting the correct version of the story out to the people in the correct context from the start.

HIV quiz widget

Here is an educational widget I heard about here at the 2008 International AIDS
Conference in Mexico City. It demonstrates the impact that the HIV
pandemic is having on children in a quick and clever way. Nice idea.

Get this widget!