Biomedical Prevention is Always About Social Justice, Too

Since 1983, when Michael Callen and  Richard Berkowitz wrote “How to Have Sex in an Epidemic,” most HIV prevention work has focused on individual behaviors, particularly around sex and drugs.  The prevention symposiums here are exploring many other prevention strategies that need much more research.  The Prevention Justice Alliance is calling attention to the structural drivers of HIV—socio-economic factors like racism, poverty, mass incarceration, homophobia, and homelessness—and showing that to defeat AIDS we must fight for social justice.  And this morning’s discussion of “Biomedical Interventions for HIV Prevention” also made it clear that HIV science can never be separated from social issues.

Biomedical prevention interventions target people who have HIV in order to reduce infectiousness, or people who don’t have HIV to reduce their susceptibility, or both. Monica Ruiz, from George Washington University, reviewed what is being researched now, including cervical barriers, microbicides, vaccines, treating and managing STIs, and post- and pre-exposure prophylaxis (PEP and PREP)—mostly with discouraging results so far.

Anna Forbes, a longtime research activist, discussed pre-exposure prophylaxis (PREP), an ARV-based prevention tool for HIV-negative people.  She explained that  prevention clinical trials must be very large and very long, because it is so difficult to prove a negative.  Moreover, they offer no immediate benefits to their healthy participants, in contrast to treatment trials, which may prevent disease progression in participants and have in fact saved many lives.  Ethical and safety issues, she argued, are foremost. What communities need to know is: Is the product safe? Safe for whom? For women? For pregnant women? For HIV-negative people, or positive people too? And we need to know if it is ethical and, more critically, if the affected community thinks it is ethical. The specter of Tuskegee always hovers over medical research involving African-Americans and other disenfranchised people.  Finally, Anna reminded us that even biomedical interventions require behavior changes to work.

Toni Young from the Community Education Group took on the very controversial issue of treatment as prevention.  An estimated 20% of people living with HIV do not know their status.  The “Test and Treat” initiative, aka TLC+, posits that if those people were identified and started on HAART, their viral loads would be reduced and they would be much less likely to infect others.  During this 3-year study, people in the Bronx and Washington, D.C., will receive financial incentives for taking the HIV test, for being linked to care if they test positive, and for bringing down their viral load.  Unfortunately, Toni didn’t address the serious context and consequences of treatment as prevention.  The primary ethical issue is treating one group of people (HIV+) in order to benefit another (HIV-). Secondly, paying people to test, then to take medications, and then again to show decreased viral load (in order to prove adherence and that they are less likely to infect others) seems degrading and will likely exacerbate the well-founded distrust of medical science so pervasive in low-income Black communities.  Thirdly, seeking out HIV+ people specifically to get them on HAART seems to reinforce the idea that pharmaceutical profits are the primary motive in routine testing initiatives.  Finally, organizations and institutions that promote routine testing should stand up and call for the repeal of all laws that make it a crime for a person who knows that they have HIV to potentially expose or infect others.  It is surely unethical to bribe people to test for HIV when having that knowledge opens them up to criminal prosecution.

The last speaker, Cindra Feuer of the AIDS Vaccine Advocacy Coalition (AVAC), gave a lucid explanation of the different types of HIV vaccine efforts and why a vaccine is so difficult to develop. Vaccines work by teaching the body to recognize a pathogen and to react when it enters the body, either with antibodies or killer T cells. But HIV is complicated because it prefers to colonize the very CD-4 cells that would fight it.  Over 200 vaccine constructs haven’t worked, but last year the unpromisin g Thai prime-boost AIDS vaccine trial (RV 144) showed a modest but significant 31.2% effect.

Cindra concluded that we need to fight for a vaccine that prevents infection by stopping viral replication, for research that determines what worked in the Thai trials;  and for trying more and different approaches to AIDS vaccines. And we need more community involvement to address the distrust of biomedical research that is so prevalent, and so bitterly deserved, in the most affected communities.