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Despite Officials’ Embrace, Skepticism Remains on Ending AIDS Plan

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The December 1 panel at the Housing Works Bookstore Café included (l. to r.) “CBS Sunday Morning” contributor Mo Rocca,  Dr. Mary Bassett, Dr. Mark Feinberg, Charles King, Gay Men’s Health Crisis executive director Kelsey Louie, and Chase Strangio of the American Civil Liberties Union. | DONNA ACETO
The December 1 panel at the Housing Works Bookstore Café included (l. to r.) “CBS Sunday Morning” contributor Mo Rocca, Dr. Mary Bassett, Dr. Mark Feinberg, Charles King, Gay Men’s Health Crisis executive director Kelsey Louie, and Chase Strangio of the American Civil Liberties Union. | DONNA ACETO

A World AIDS Day event featured some skepticism about central components of the Plan to End AIDS, which aims to reduce the number of new HIV infections in New York State from the current roughly 3,000 a year to 750 annually by 2020.

“The thing that concerns me most is the issue of adherence,” said Dr. Mary Bassett, the city’s health commissioner, referring to pre-exposure prophylaxis (PrEP), which involves the use of anti-HIV drugs by HIV-negative people to keep them uninfected.

Bassett’s comments came at a December 1 event held at the Housing Works Bookstore Café on Crosby Street in Manhattan. Notably, she was joined on the panel by Charles King, the chief executive of Housing Works, an AIDS group, who is credited with developing the plan along with Mark Harrington, the executive director of the Treatment Action Group (TAG). King has been the plan’s leading champion.

City health commissioner, leading vaccine advocates voice questions whether PrEP is enough

While the plan relies on providing a range of services to HIV-positive and HIV-negative people, at its core, it uses anti-HIV drugs to cut new HIV infections. Along with PrEP, the plan relies on post-exposure prophylaxis (PEP), anti-HIV drugs used by people with a recent exposure to the virus to keep them uninfected, and treatment as prevention (TasP), which treats HIV-positive people with anti-HIV drugs so they are no longer infectious.

All three drug regimens are highly effective when taken correctly, and the science says the plan should work. But it is a very ambitious plan and the first of its kind. While various types of prophylaxis that pre-date PrEP and PEP have been used before, Gay City News could not find a single example of any form of prophylaxis being used on the scale envisioned in the Plan to End AIDS. Only one infectious disease, smallpox, has been eradicated and that was done with a vaccine. Vaccines and cures have significantly reduced the incidence of other infectious diseases. TasP has worked well against some infections, such as tuberculosis, in some places.

Bassett’s concerns about PrEP adherence, concerns she has expressed since becoming health commissioner in early 2014, also have some basis in science. In early PrEP studies, adherence was a problem, with any new HIV infections coming among those who did not take Truvada, the only drug approved for PrEP, correctly.

More recently, a study of 200 gay men aged 18 to 22 in 12 US cities found poor PrEP adherence among the African-American men, who accounted for 53 percent of the participants. The amount of Truvada detected in their blood never rose above the level indicating they were taking the pill at least four days a week, which is the minimum dose required to obtain the anti-HIV protection.

“Our Black/ African-American youth were consistently below four-plus pills per week for the entire study,” Sybil Hosek, the study’s lead author and a psychologist at the Cook County Health and Hospitals System in Chicago, said at a July press event held at an International AIDS Society meeting.

The study followed the men for 48 weeks and reported four seroconversions during that time, for an incidence rate of 3.29 percent, which is high. The white and Latino men in the study consistently had Truvada levels in their blood that showed they were taking four or more pills a week.

The state’s epidemic is driven by new HIV diagnoses in New York City. The rate of new HIV infections among city gay and bisexual men has remained high and unchanged for years.

In 2014, there were 2,718 new HIV diagnoses in the city and 81 percent, or 2,194, were in men. Among men, 74 percent of the new HIV diagnoses were in gay and bisexual men. African-American men accounted for 39 percent, or 847, of the diagnoses among men, Latino men accounted for 34 percent of the diagnoses, or 743, and white men accounted for 21 percent of the diagnoses, or 467. So the population that New York must reach with a PrEP message — African-American gay and bisexual men — to get to 750 new HIV infections by 2020 is the population that right now looks like the one that is most likely to have adherence problems.

Bassett was not alone in expressing some skepticism about the plan. Dr. Mark Feinberg, the chief executive at the International AIDS Vaccine Initiative, said that the AIDS epidemic could not be ended without a vaccine.

“I honestly don’t know when or if we will have a vaccine,” Feinberg said. “We’ve never made a vaccine against an infection like HIV before.”

King responded quickly.

“I want to disagree with my friend who I just met,” he said. “We don’t have a cure, we don’t have a vaccine, but we can end AIDS as an epidemic.”

Feinberg said later that places like New York and San Francisco might see success in ending their epidemics using prophylaxis and treatment. Those cities have the money and infrastructure that could make that success possible.

“PrEP can be highly effective if people take it correctly,” he said. “Unfortunat­ely, that’s not the reality around the world.”

Updated 5:17 pm, July 20, 2018
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Reader feedback

Jeton Ademaj says:
the ending clause of this sentence is simply false: "The amount of Truvada detected in their blood never rose above the level indicating they were taking the pill at least four days a week, which is the minimum dose required to obtain the anti-HIV protection." at 2 days per week, truvada-PrEP is around 75% effective, which is similar to the CDC's own study of "100% condom use" = 70% real world protection. at 3.5 days per week (literally every other day dosing), truvadaprep is 92% effective. that is an unjustifiable distortion that is easily corrected by adding the word "maximum" thusly: "The amount of Truvada detected in their blood never rose above the level indicating they were taking the pill at least four days a week, which is the minimum dose required to obtain the maximum anti-HIV protection." that CORRECTION may erode the thrust of your piece, Duncan, which is lingering skepticism about ETE, but it's almost 2016 and distorting PrEP facts well in evidence by now would be unconscionable. i hope that correction can be entered quickly.
Dec. 10, 2015, 10:47 pm
Charles King says:
Throughout this effort to End the Epidemic in New York State, Gay City News has consistently emphasized skepticism about this agenda, so it is no surprise to me that this would be the slant taken in a story about a panel that was both optimistic and honest about the challenges fast in ending the epidemic here and elsewhere. I would share that skepticism if I thought pills alone were being offered as the solution. In fact, the Blue Print spells out critical steps to address social drivers of the epidemic, including homelessness, lack of vocational opportunity, and stigma and discrimination. What we have seen in the last two weeks are tremendous advances in these areas, all galvanized by Governor Cuomo's commitment to End the Epidemic in NYS by 2020. Step by step, the Blue Print is being implemented in New York City and all across the State. From the state-wide expansion of transgender rights to the financial commitments announced in the last several weeks, we are seeing dramatic progress because Ending the Epidemic has captured our imaginations as something we can achieve. While skepticism may keep us honest, we have already seen considerable action, which leads me to wonder what the skeptics think should be the alternative.
Dec. 11, 2015, 6:13 am
Paulscoles says:
Kudos to both preceding comments; they're spot on: Ademaj highlights the danger of reading statistics upside down. It's absolutely not true that "you can prove anything with statistics", but if you use them correctly, they will show you where the truth is. In the case of PreP, the truth is that this treatment, used appropriately, is as close to 100% effective as any treatment ever gets. Highlighting the statistically remote possibility of failure is irresponsible. King points out that no treatment can succeed in isolation. Without intensive public education ( and yes, that's going to include a lot of TV and billboard ads that will cause apoplexy at Fox News, but that's not necessarily a bad thing) the End the Epidemic program cannot succeed. Without efforts to identify and address the root causes in communities at particular risk, the program won't work. That's not an excuse for inaction, rather, it is a call for greater action. As an antidote to its snarky negativity, I suggest Gay City News reprint Dr. Anthony Fauci's editorial in the current New England Journal of Medicine. Fauci, the Director of the National Institutes of Health, and himself an AIDS research pioneer urges that public policy follow the science: "Taken together, these studies provide an evidence-based blueprint for effective treatment and prevention of HIV infection and will serve as critical tools in the fight to end the HIV–AIDS pandemic. However, in order to realize that promise, the political will must be mobilized to match the scientific evidence and provide the financial and human resources necessary to dramatically scale up HIV testing and treatment around the world. The science has spoken. There can now be no excuse for inaction." We have the tools. In the richest city in the world, we have the money. All we lack is the political will. The Governor and the Mayor, to their lasting credit, have taken the lead. Everybody else needs to shut up and get out of the way
Dec. 11, 2015, 9:59 am
Jeton Ademaj says:
I would also direct readers to my exchange with Duncan Osborne on the ACT UP NY group page.
Dec. 11, 2015, 12:45 pm
paulschindler says:
Charles, the skepticism was voiced by the city health commissioner and the head of IAVI. Would your recommend that we ignore their comments in our reporting? Would you recommend now that the Plan has been established that we move on to other issues?
Dec. 11, 2015, 1:04 pm
paulschindler says:
And, Charles, while you say we are consistently skeptical, I would point out that I doubt any newspaper has put more effort into writing about and advocating for key elements of the plan and related public health initiatives, including: 1. the 30 percent rent cap 2. HASA for All 3. Ban on use of condoms as evidence 4. Availability of PEP 5. Greater inclusion of African-American leaders in the development of the plan. 6. Keeping open the Chelsea clinic to provide critical outreach and access for many gay and bi men for whom PrEP is a good solution. You've been a key play in all this, and you seem confident that all the pieces are in place to move the plan forward. If you feel that our having pointed out –– in the period prior to the governor's $200 million commitment last week –– that very little money had been targeted for the Plan is an overly negative or skeptical stance, I have to disagree. Maybe you were always confident the Plan would get that sort of support, support that it was you who were saying over and over again it needed. Those discussions, however, were not public and our job is to point out, based on available information, whether or not public officials are delivering on their commitments. You may or may not have seen that on December 1 we published a story titled "For Plan to End AIDS, Cuomo Offers $200 Million, de Blasio Expands Services to All With HIV," a story that clearly emphasized the way in which the city and state were stepping up in ways that they hadn't before. Our job is to scrutinize all of this with the information available to us and call it like we see it. Our job is not to be cheerleaders, so sometimes "the team" will be disappointed in what we write. Skepticism may strike some as negative, but I think in the long run skepticism will advance the goals all of us are seeking.
Dec. 11, 2015, 1:28 pm
supasize mega says:
Nice move in eradicating HIV infection.
June 16, 2016, 12:28 am
fcbuscompany.com says:
Do we really want to travel in hermetically sealed popemobiles through the rural provinces of France, Mexico and the Far East, eating only in Hard Rock Cafes and McDonalds? Or do we want to eat without fear, tearing into the local stew, the humble taqueria's mystery meat, the sincerely offered gift of a lightly grilled fish head? I know what I want. I want it all. I want to try everything once.
Oct. 24, 2016, 5:36 am

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