The biggest story out of one of the world’s biggest conferences on HIV-AIDS, which was held in Seattle this week, was that new studies further demonstrated the benefit of taking the anti-HIV drug Truvada to prevent infection by HIV.
“We were able to show that these strategies were highly successful, reducing the risk of HIV infection by 86 percent,” said Jean-Michel Molina, a physician at the Hôpital Saint-Louis in Paris and lead investigator of one of two studies presented at the annual Conference on Retroviruses and Opportunistic Infections (CROI), findings that some say represent a game-changer for the HIV pandemic.
For one gender, anyway. Unfortunately for women, who today account for about 60 percent of those infected with HIV worldwide, the studies only show a benefit for men.
“For 20 years, we’ve been saying we need to give women a prevention tool they control and don’t need to get anyone’s permission to use,” said Anna Forbes, a women’s health activist and HIV expert based in Washington, D.C. “But this discussion is almost totally focused on preventing HIV infection in men.”
Forbes delivered her complaint to the thousand or so scientists, health workers, activists and others at CROI attending a panel discussion on this prevention strategy known as PrEP (pre-exposure prophylaxis). She said too much attention by the biomedical community remains focused on men’s needs, mostly high-risk gay men, and not enough resources or efforts are targeting women – even though they represent most of the pandemic today.
“Maybe it’s partly the historical focus, maybe it’s just sexism, I don’t know,” Forbes said. “But it needs to change.”
Molina’s study, done in France and Canada with the perhaps unintentionally implicating (in English) trial name Ipergay, was focused on high-risk, sexually active gay men or men who have sex with men (MSM). Participants were asked to take the anti-HIV pill Truvada 24 hours prior to having sex and for two days after. Another study done in Britain, called Proud, required participants to take the drug continuously to prevent HIV infection and also saw an 86 percent reduction in transmission.
The results of these two trials had been known prior to the CROI confab, but the findings were discussed in greater detail this week and were regarded as the most significant, latest developments in HIV research.
“Truvada is only registered in one country, the United States, for use as a prevention strategy,” noted Mitchell Warren, executive director of the HIV prevention advocacy group AVAC. “We need to get this into wider use around the world.”
While everyone celebrated the success of PrEP in men, some like Forbes wanted more attention to the failure so far to make this strategy work for those who, arguably, need it even more – women.
“We really need to grapple with this,” said Helen Rees, an obstetrician-gynecologist and world-renowned HIV researcher based in South Africa. Rees presented results from a study she led, called Facts, that showed the use of the same anti-HIV drug (generic name tenofovir) used by women as a vaginal gel before and after sex failed to show any significant protection against infection.
“We have seen that oral PrEP (pills) works for women in discordant couples (where one partner is HIV-positive and the other is not),” she said. But that’s a pretty specialized sub-group, Rees noted. The Facts study, she said, was targeting young, single women – those at high risk for HIV, especially in southern Africa.
“When I heard of Helen’s results in this trial, the headline that came to my mind was: Women’s Prevention Needs Still Unmet,” said Sharon Hillier, also a women’s health expert and a leading HIV researcher, based at the University of Pittsburgh. Hillier, with Jeanne Marrazzo of the University of Washington, led an earlier PrEP study called the Voice trial in which women were asked to use a vaginal microbicide that showed promise for preventing HIV.
The Voice trial failed, mostly because women did not use the microbicide – even though they said they did.
“What we discovered is that, for these young women, there is a lot of stigma associated with doing PrEP,” Hillier said. Taking pills that prevent the risk of HIV, she said, is often seen by a woman’s partner, or the community at large, as evidence of either promiscuity or that they are already infected. Inserting a gel just prior to sex isn’t any easier for women to accomplish, she added, for many of the same reasons.
The PrEP approach shows scientific promise for women, Hillier said, but women don’t live in a lab. The challenge, she said, for the research community now is to find a strategy that works culturally, socially and technically for women.
“Until that happens, the bottom line here is that women’s needs for prevention within the pandemic are going to remain unmet,” Hillier said.