Are we PREPPED for PrEP?

PrEP is short for Pre-Exposure Prophylaxis of HIV to prevent transmission of disease. Recent studies have demonstrated that a combination medication tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC) and the FDA has approved it's use.  Our own, Infectious Disease clinician, Erika Aarons, RN, CRNP, MSN was on the FDA Advisory panel that evaluated and voted upon approval of this new medication. Read the article here. The FDA resport is here.

This news is exciting in that this the first medication combination identified in 30 years that if taken regularly, can result in a 90% reduction in risk of an HIV negative partner acquiring the disease from their HIV positive partner. So, in serodiscordant partners (one with HIV/AIDs, one not) this is an incredible breakthrough.

Here's a few important issues:
*Medicine only was effective at that rate if taken every single day - those who did not have sufficient medication in their blood did not have the same result
*HIV transmission in serodiscordant couples occurs outside of a couple in 25-30% of cases (Donnell 2010; Cohen 2011)
*Estimated cost of daily therapy is likely to be in excess of $10,000/year.
*Lifetime costs (2010 numbers) for HIV treatment is $379,668 (excluding reproductive health related issues)

So PrEP is amazing scientifically, yet does it remain a wish versus a reality? This is a great example of the challenges faced when we address paying for prevention. I wonder how expensive or inexpensive an intervention would need to be to get support to prevent Diabetes?

HIV at the onset was (fairly) quick and (mostly) deadly disease - with the onset of HAART, HIV can become a chronic disease. At the beginning when there was only one or limited agents, medical science had not demonstrated how sneaky the HIV virus can be. It is now known that to combat disease, people often need three types of anti virals to keep the disease from changing and becoming resistant. I think of it as making a corral for a horse with three fences - keeping it within the triangle. If we use one or two or infrequently use the medicines, HIV learns quickly (becomes resistant) and makes the medicine ineffective.  Regular medicine use is challenged for any medical illness - HIV is no different. But there are some difference with HIV - CDC estimates that 1 in 5 people have disease and are unaware. So in place where there is a lot of HIV, people ages 11 and up and all people sexually active should have HIV screening as part of their routine evaluation. In the Philadelphia Ujima project, we talk about "Know Your Numbers, Own Your Health."

Perhaps next steps need to be more medical advances resulting in more medicines that decrease the cost of transmission preventing medicines?

Kaiser Family Foundation. www.statehealthfacts.org. Data Source: Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention-Surveillance and Epidemiology, Special Data Request; 2010

Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375:2092-2098

Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505

Kaiser Foundation 2012 Fact Sheet on Women with HIV here

Hot Off the Press  Aaron, E., Cohen D. Pre-exposure Prophylaxis for the Prevention of HIV

Transmission to Women in the United States AIDS 2012, 26:
000–000

Planning and Intention - A bit more about health and reproduction.

 

So concluding our journal club today where we had an interesting discussion about the ACES study (adverse childhood experiences study) and unwanted pregnancy (Dietz, P, Spitz, A. et al. Unintended Pregnancy Among Adult Women Exposed to Abuse or Household Dysfunction During Their Childhood. JAMA.1999: 282:1359-1364.),  I wanted to add a bit more on the unintended pregnancy issue.

One of the things we discussed was the nuances of unexpected and unwanted in terms of pregnancy. So here's some data from the National Health Statistics Reports July 24, 2012, Intended and Unintended Births in the United States:P 1982-2010. This study looked at data regarding the attitudes of women who had live births.

*Percentage unintended at time of conception 37% in the group evaluated.
*Group that demonstrated significant decline since 1982 = married, non-Hispanic white women.
*Disparity seen between them and unmarried women, black women or women who have educational or economic disadvantage.
*Intended births and teen mothers - only 23% were intended (2006-2010), therefore 4/5 unintended.
Of interest, the authors talk about unintended births as being measured as intended (meant to get pregnant); mis-timed (wanted to, but not now) and unwanted (not wanted to get pregnant or not wanted the infant in the birth order it came into.) They also talk about an 'alternative' definition breaking down the term unintended birth into two elements - action (pregnant/not) and affect or emotional interpretation (wanted or not) They felt that the data was concordant with either evaluation.
It does make you wonder though if the composite effect blurs out subgroup differences here.

Particularly interesting was the authors mention that
*Women in poverty (below 150% ) make up 56% on unintended births and only 35% intended
           (supporting the previous blog mention of poverty as a marker for unplanned births)
*More than one in five intended pregnancies and births (22.8%) are in teenage (ag 15-19) mothers. (birth rate 40.2 births/1000 in 2008. ) If we could disrupt factors such as poverty and influence the situation where unintended births to teens was postponed until age 20, we could have teen birth rates drop for 11% of all births to 4%!

Here's an interesting video about the benefits of contraception from the Guttmacher Institute

In the Olympics of Teen Pregnancy, The U.S. 'Wins' While Young Women Lose.

It is known that an association with becoming a teen mother is having had a teen mother. It is also known that economic options for young women are limited by becoming a teen mom. But is the cause role modeling (‘do as I did’) or are there other factors in play? Do we have it backward that teen motherhood results in economic limitations?

In contrast to all other developed countries (Canada, Norway, Switzerland, Russia or Germany) teens are more likely to become pregnant. U.S. teens are 2.5 more likely to become pregnant than Canadians; 4 times more likely than Germans and 10 times more likely than Swiss teens. Even compared to Russian teens (who are second to the U.S), U.S. teens are 25% more likely to become pregnant.

 A 2012 study by two economists -  Melissa S. Kearney, PhD, Associate Professor at the University of Maryland and Phillip Levine, PhD Professor at Wellesley College evaluated the linkage between income inequality and teenage childbirth rates.

Their conclusion is that the most influential factor in teen pregnancy is poverty – if young girls believe, and perhaps accurately so, that their life’s trajectory is limited or that they don’t have one, then becoming a teen mother miring them in poverty is merely hastening what is only going to happen anyway.

Certainly, education, literacy, unemployment are all elements that influence the situation (as does role modeling) but are teen pregnancy rates merely a proxy measure of the wealth gap in the U.S.?

What do you think?
On the left is the map of poverty in the U.S 2006-2010; on the right is the map distribution of teen birth rates in 2010.
A teen in Mississippi is four times as likely to become a pregnant teen as a youth from New Hampshire. Kearney and Phillip describe zones of economic despair with evidence of outcomes as seen by teen birth rates.



NOTES: Data for 2010 are preliminary. Access data table for Figure 6 [PDF -175 KB].
SOURCE: CDC/NCHS, National Vital Statistics System.

There is a lot of optimism that the rate of teens birth is on the decline, see the CDC data brief here, however clearly we have a lot of more to do in this area. Some $10.9 billion dollars is spent annually on teen childbearing. Maybe we need to consider the timing of these resources and not be exclusively reactive?



Here’s a link to their March 2012 paper 

    Why is the Teen Birth Rate in the United States so High and Why Does it Matter? 

Here's a link to their previous work

Income Inequality, Early Non-Marital Childbearing.."Culture of Despair".



 

Kearney, Phillips. NBER Working Paper No. 17965. March 2012. JEL No. I28,J13