2.1.2 Treatments, treatment as prevention, and “functonal” cure
It would seem we are at a pivotal turning point in the fight against HIV and AIDS. Although there is no true cure for AIDS at this time and no vaccine yet to prevent it, the development of several ART regimens has changed the course of the epidemic (Dieffenbach and Fauci 2011), lowering the death rate of PLWHAs around the world.30 Further, it seems that using these same regimens prophylactically with the non-infected partners of HIV-positive persons (i.e., preventively) can actually decrease the new infection rate (by blocking transfer) dramatically. And it looms hopeful that certain uses of ART might actually provide a functional cure for many in the future.
2.1.2.1 Early ART therapies
Antiretroviral therapies first began to be developed for use against HIV between 1985 and 1990 (Broder 2010). The discoveries led to multi-drug therapies (often referred to as cocktail therapies since they involve the use of various drug combinations), which began to significantly lower the death rate from AIDS in the places where they were being used. With the advent of highly active antiretroviral therapy (HAART), mortality among patients with AIDS who were under ART treatment was nearly half what it was prior to the “HAART era” (Rathbun 2012), and life expectancies for those with HIV rose from months to decades (Dieffenbach and Fauci 2011). Many of these new treatments were successful at reducing the amount of HIV in the blood to an undetectable level. However, these drugs were found to control the virus but not to eradicate it. Once a person stopped treatment, HIV again began to grow in the body. The new treatments began to shift the cultural model to understanding AIDS as a chronic, manageable condition. “Living with AIDS” rather than “dying from AIDS” became the new model.
In the early years of antiretroviral drugs (ARVs) these new medical advances had little impact on the spread of HIV worldwide.31 At that time, 95 percent of HIV infections occurred in the developing world and the developing world also experienced ninety-five percent of all deaths due to AIDS (UNAIDS 1999). There was a large gap between East and West (what I termed “the West and the rest” in the earlier edition) in their ability to access these new treatment possibilities. Many of these treatments at that time cost over one thousand dollars a month per person—an unrealistic hope for an AIDS sufferer, for instance, in Nepal, a country of socialized medicine, where the government then allocated the rupee-equivalent of seven dollars (US) per person per annum to health care and where the underlying trend was an annual decrease in health expenditure (Smith 1996:140). The cost of these treatments made them impossible for developing nations to ever consider. So, while the cultural model began to shift to “living with AIDS” in the West (for those who had access to ART), it remained “dying with AIDS” in the rest of the world (for those who did not have access to ART). In the next section, I will discuss the socioeconomic implications that these changing cultural models have had and will continue to have in the future.
In recent years an effort has been made to make these life-saving drugs more widely available to all. Today ART is considered “standard fare” in HIV treatment and is often made available for free (via a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria). Even so, by 2008 only 13 percent of those who needed it had access to ART in Nepal (USAID 2008). So, even though ART is now “available” free of charge in Nepal, there are still structural problems preventing access for all. And in 2011 the Global Fund announced an acute funding crisis, which may limit the fund’s ability to continue providing these ART drugs free of charge in the near future (Boseley 2011).
2.1.2.2 ART as prevention
In 2011, a study conclusively confirmed what had long been suspected: that treating HIV-positive persons with ART would significantly reduce their chances of transmitting HIV to their sexual or drug-using partners. This landmark study (Cohen et al. 2011) concluded that ART treatment of an HIV-infected partner reduced the risk of transmission to the uninfected partner by 96 percent. Thus, the study definitively proved that early HIV treatment with ART has a “profound prevention benefit” (CDC 2013). The practice of treating HIV-infected persons as a method of reducing transmission came to be considered “treatment as prevention” (CDC 2013). Science Magazine hailed the discovery as the “breakthrough of the year” (Cohen 2011:1628).32
The discovery instantly worried some that it might be hailed as a kind of “magic bullet” and that future prevention efforts might therefore favor an overdependence on treatment-based prevention efforts (to the exclusion of all other prevention efforts). Soon after the announcement, well-known HIV and AIDS researchers Edward Green, Allison Herling Ruark, and Norman Hearst commented:
This week, the United Nations General Assembly meets to discuss progress against the HIV and AIDS epidemic amid news that antiretroviral drugs can drastically reduce HIV transmission from infected to non-infected partners. The U.N.’s AIDS agency, UNAIDS, has already called this news a “game changer” and at this week’s meeting will doubtless call for massive infusions of donor funding in order to implement this treatment-as-prevention approach.
Nearly as certain is that little will be said about investing in programs to encourage the kind of fundamental behavior change, particularly faithfulness between sexual partners, that has already saved millions of lives worldwide. Serious investment in such programs would cost a tiny fraction of the vast sums required for HIV treatment. Yet there is a serious lack of political will to invest in simple, low-cost programs which address the real drivers of the HIV epidemic, such as multiple sexual partners. (Green et al. 2011)
It seems that these words were almost prophetic as the discovery was “translated rapidly into policy for the global response” (Cohen et al. 2012:1439). The announcement created a firestorm of debate among HIV researchers, which is still raging as of this writing. At the heart of the debate seems to be a concern over resources. Some fear that already-limited resources (currently thinly spread over a variety of non-treatment prevention approaches) will be further appropriated from these approaches (such as behavioral change), to be spent more heavily on this new “treatment as prevention” drug-based method. And the concern seems warranted. In 2003, U.S. President George W. Bush initiated the President’s Emergency Plan for AIDS Relief (known as PEPFAR), a program that committed 15 billion dollars over five years (2004–2008) to be used globally to fight HIV and AIDS. The plan allocated 80 percent for treatment and care (e.g., ART delivery) and 20 percent for prevention (e.g., sexual behavioral change efforts). In 2008, PEPFAR was renewed by Congress, shifting emphasis toward “expanding existing commitments around service delivery” (i.e., treatment) and removing the 20 percent funding allocated for prevention altogether (Moss 2008). The debate, pitting behavior-change prevention efforts against other methods (e.g., treatment as prevention, condom distribution, etc.), is not new and it seems to be indicative of a possible ideological divide among HIV and AIDS researchers.33 And it is difficult to assess what the final repercussions of this funding shift will produce.
2.1.2.3 Limitations of ART
One of the first limitations to ART as prevention is that subsequent studies have shown far more modest results. A study published in The Lancet in 2012 (Jia et al. 2012) found that ART used to prevent HIV transmission in serodiscordant couples in China produced a far more modest reduction of 26 percent.34 While certainly significant, the results are far from the 96 percent findings of the earlier study, suggesting that while ART as prevention is a positive step forward, it alone may not be the silver bullet researchers had hoped it would be.
Many field-based anthropologists working in developing countries seem to have a less-than-optimistic view about the ability of ART (i.e., treatment as prevention) to completely solve the AIDS problem. Fauci, in an earlier article (Fauci 2011), had conveyed great optimism that ART would be the final answer to the pandemic. In a follow-up to the article, Jonathan Imbody, the Christian Medical Association Vice President for Government Relations, asked Fauci directly about the remaining barriers to ART delivery and compliance (Christian Medical and Dental Association 2011). When questioned about the challenge of getting AIDS patients to adhere to their medicines, Fauci “acknowledged the need noting, ‘we have to do behavioral intervention along with the biological.’” Imbody then went on to list various reservations that a number