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This post was published on 15/07/11 in Science.

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  1. Comment by Gwinyai Masukume, 16/07/11, 03:22:

    “Let’s face it, HIV has reached eye-watering levels in many sub-Saharan African countries because both voters and governments have been in deep denial about their own, and their neighbours’, propensity to have sex with someone who is not their single life-time partner.”
    As always, I congratulate Dr Pisani for her erudite and thought provoking analysis of PrEP studies. I would like to challenge the above quoted statement:
    HIV is known to be a disease of poverty along with TB, malaria, maternal mortality and so on. In Zimbabwe (which is a sub-Saharan African country) for example, it is widely known by voters and the government that people have a ‘propensity to have sex with someone who is not their single life-time partner’. The social phenomenon of ’small houses’ (extramarital heterosexual sexual intercourse) is commonly parodied in the media and during social interactions. I specifically mention extramarital heterosexual sexual intercourse because HIV largely has a heterosexual face in sub-Saharan Africa. Behavior change, for example, the reduction in the number of multiple concurrent sexual partners has been identified as one of the reasons for the declining HIV prevalence in Zimbabwe.
    In conclusion, denial exists in sub-Saharan Africa but is it very different from the denial that exists elsewhere?

  2. Comment by Jon Jay, 19/07/11, 05:25:

    I agree that in general, treating the HIV-positive partner will be a better use of ART than PrEP in the HIV-negative partner. But the new study results will be useful for discordant couples in which the positive partner is not willing to start ART (or even be tested in the first place). People often face HIV risk because their male partners won’t use condoms–and we can imagine that male partners who won’t use condoms would often be similarly unwilling to be tested for HIV or begin ART before it’s necessary for their own health. PrEP (like microbicides) could be used without a partner’s knowledge or consent. So I think the new PrEP data are potentially useful for discordant couples, despite the efficacy of the 052 regimen.

    I think another interesting question (especially given what you’ve said about the CDC study in Thailand among IV drug users) is the ethics of these studies’ having continued after the HPTN 052 results were released. At that point, there was a known effective intervention (early ARV treatment of the HIV+ partner) which was not being provided to study participants–instead, study participants continued on either to placebo or PrEP (which later failed to show effectiveness among women in FEM-PrEP). So there were probably some preventable infections, especially in the larger Partners study. On the other hand, immediate therapy in discordant couples is still not a worldwide standard of care. Any thoughts? This may seem moot because the studies were just about to finish, but the larger Partners study was slated to continue longer before being stopped by the DSMB.

  3. Comment by Eva, 23/07/11, 07:58:

    I can´t find where the Botswana study says the trial participants were in serodiscordant relationships, do you have a link?

  4. Comment by Roger, 31/07/11, 11:08:

    The use of PrEP in serodiscordant couple when treatment is more efficacious did puzzle me too. However, after a number of discussions a twofold rational started to emmerge:

    (a) the HIV-neg does not know if his/her HIV+ partner is taking his drugs properly to the extent that (s)he is not infectious and (b) that same HIV-neg partner may be having some fun with someone else than her/his regular, HIV+ partner on ART.

    Regarding (b) my response is that the “third party” may not neccessarily be HIV+, and even so, if (s)he was on treatment too that would limit the extent of the problem.

    Regarding point (a), I think it illustrates a potential weekness of T4P.

    But what this discussion is really ignoring, is that the problem is not about who should be treated, but about (un)safe sex. Once more, people are talking pass each other and resolve to medical interventions rather than addressing the root cause of the problem.

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