Early RNA test ------- Infection can be detected within 10 days of exposure

[veritas]

Implications for testing is multifold:

RNA Testing for HIV Instead of Antibody Testing Could Detect Early Stage of HIV Infection And Would Likely Improve Prevention AND Allow for Early HAART' Could it Prevent Accelerated Aging?
 
 
 
  Reported by Jules Levin
Numerous studies have looked at HAART in acute in HIV infection to find little benefit in terms of longer term improved undetectability rates. HOWEVER, recent concerns that HIV accelerates aging raises the question again if HAART during the very early stages of HIV infection would be beneficial in the very long term in terms of slowing accelerated aging in HIV+ individuals, and these studies have not been done. What do I mean? In the past 2 years we have become acutely aware that rates of non-AIDS complications (liver disease, cognitive impairment/brain dysfunction, cardiovascular disease, bone disease, renal disease) are increased and are causing premature deaths. It looks like HIV itself plays a serious role in this by leading to senescent T-cells soon after HIV infection (prematurely aging T-cell repertoire), leading to ongoing inflammation which apparently can occur despite undetectable viral load, and hyper activation of the immune system which also appears to occur despite undetectable viral load. Dealing with these questions related to aging has become THE QUESTION of the year.
 
The NIH has issued 3 RFPs to fund aging research and this is or should be the most discussed subject in the HIV field. Some clinicians and clinical researchers do not appear very interested or knowledgable about the question as reflected by a meeting I just attended on Aging & HIV where many clinical researchers did not appear to me to really understand the imperative of this question or just had no ideas about it. But in real research science circles like at Alan Landay's Immunology Lab in Chicago, at NIAIDS, in the MACS Study Group, at the Immunology Lab at USC or UCLA they are conducting REAL aging with HIV basic science studies to examine these questions--to understand the mechanisms and eventually to perhaps find interventions. Granted, I think finding interventions will NOT be easy, but unless we focus on this we certainly will not.
 
THIS IS the number one issue for patients in the USA and Western World with HIV and certainly for those who have been on HAART and moreso for those aging, past 50 yrs old. Soon, death rates will dramatically increase, in my opinion, due to increased rates of non-AIDS comorbidities. HIV+ indviduals aging past 50 yrs tend to be more frail as evidenced by a published study finding frailty significantly increased in HIV+ individuals as they age compared to HIV-negative individuals.
 
Osteopenia rates are 60% in HIV at the average age of 45 yrs in cohort studies, and fractures increase mortality in the aging HIV-negative population, and a recent study by Grinspoon found fracture rates were HIGHER among HIV+ vs HIV-negs. This leads me back to the original point. Is there a benefit to starting HAART immediately after infection? I think we would need to do a study to see if you could reverse senescent T-cell development by this, so we would have to understand perhaps when senescense sets in and is it reversible. Does senescence begin upon immediate infection or does it ocurr after 1 year of infection? These are important questions.
 
RNA Tests for New H.I.V. Infection Not Widely Adopted: "would encourage early care and effective prevention".....
 
"And if everyone were tested, the stigma surrounding AIDS testing might decrease"..... 'routinization" of AIDS within the range of infectious diseases; Dr. Anthony Fauci..."Treatment," he says, "would be prevention."
 
By DAVID TULLER
Published: April 30, 2009
In December 2008, after a weekend of sex fueled by methamphetamine, Chris, a San Francisco man in his early 30s, sought out testing for sexually transmitted diseases at Magnet, a clinic serving homosexual men in the city?s Castro neighborhood.
 
Tim Ryan, RN, clinical supervisor at Magnet in San Francisco, performs a blood draw -- the method used to collect specimens for HIV RNA testing.
 
Staff members tested him for H.I.V.twice: first with a standard rapid test, which detects H.I.V. antibodies in saliva or a drop of blood, then with a blood test for genetic traces of the virus itself.
 
Although the antibody test can deliver immediate results, it is not likely to identify an infection that has occurred in the past month. The genetic test, which looks for bits of the virus?s ribonucleic acid, or RNA, can identify infections in a week to 10 days. Chris, who asked that his full name not be used, was told that his antibody test was negative. But his RNA test was positive, making him one of the few whose diagnosis came in the acute, or primary, phase of infection, when the virus is replicating aggressively but the body has not yet mounted an effective immune response. Many public health officials and AIDS experts increasingly see identification of the newly infected as an important next step in controlling the spread of H.I.V., the virus that causes AIDS. Yet the RNA test, the only one capable of detecting the newest infections, has not been widely adopted for this purpose.
 
"People with acute infection have more virus in the blood, and if they're unaware they're infected, they're more likely to engage in risky behavior," said Dr. Kenneth Mayer, a professor of medicine at Brown University and a leading AIDS researcher.
 
Finding those with new infections sooner and providing counseling will help prevent them from infecting others, Dr. Mayer said. As it stands, studies suggest that the recently infected could be the source of 10 percent to 50 percent of all new H.I.V. transmissions.
 
"We have a serious ongoing problem of H.I.V. transmission that hasn?t been adequately addressed," said Dr. Jeffrey Klausner, director of S.T.D. prevention at the San Francisco Department of Public Health.
 
The Centers for Disease Control and Prevention has conducted pilot studies of RNA testing in some cities, but current national guidelines focus on more widespread antibody testing to identify some of the estimated 250,000 Americans who are infected but do not know it. Routine RNA testing has been tried rarely, in part because it is expensive, involves drawing blood and complicated laboratory work, and does not provide immediate results.
 
But health departments in North Carolina and San Francisco have used the tests in some settings for several years, reducing costs by pooling many blood samples and testing them together. Officials there have reported finding dozens of cases of acute infection that were not detected by the standard test, and they have advocated for much wider use of the RNA test.
 
The Magnet clinic began its RNA testing program last year to serve gay men who engage in unprotected sex and are in social and sexual networks at the highest risk of acquiring H.I.V. "Early detection is a prevention strategy," said Judy Auerbach, public policy director of the San Francisco AIDS Foundation, which runs the clinic.
 
Chris, the San Francisco man whose infection was diagnosed with an RNA test, said the early diagnosis had allowed him "to be more proactive, to get right on it at the start and feel a little bit more in control."
 
Reduction of H.I.V. transmission rates has taken on renewed urgency. Last year, the disease control agency raised its estimate for annual new H.I.V. infections to 56,000, from 40,000. In 2008, the agency reported that from 2001 to 2006, H.I.V. diagnoses increased annually by 15 percent among young African-American men who have sex with men.
 
A less expensive alternative to the RNA test may not be far away. The centers recently began a study to compare RNA testing with an advanced version of the standard test, which is easy to administer and can detect a substance produced by the virus in its early stages.
 
The newest test, called an antibody-antigen test, appears able to identify 85 percent of the acute H.I.V. infections picked up by the RNA test and could be commercially available next year, agency officials said.
 

--------------------------------------------------------------------------------
The Invisible Epidemic
 
Wash Post
By Michael Gerson
Friday, May 1, 2009
 
As I was waiting for the results of my AIDS test, the health lecture from my counselor Anthony was calm, explicit and, um, informative. The five bodily fluids that can transmit the HIV virus. The proper way to open a condom package to avoid rips (I did it all wrong). Certain uses for Saran Wrap not specified by the manufacturer.
 
An AIDS clinic in Washington -- a new ground zero in the American AIDS crisis -- is no place for the squeamish. The test itself looks like a pregnancy test, in its small, white, plastic momentousness. The swab at the end is run across the gum line; no blood is drawn. The results take about 20 minutes and are 99.1 percent accurate.
 
I was visiting Unity Health Care in Ward 7, an outpost of tidy medical professionalism in a poor section of the city. Here the talk of epidemics has nothing to do with swine flu. The Centers for Disease Control and Prevention describes a health epidemic as "severe" when more than 1 percent of people in a geographic area are infected. The HIV infection rate in Ward 7 is at least 2.4 percent -- higher than the national rate in Ethiopia, Ghana or Burundi. Among 40- to 49-year-olds in the District, 7.2 percent are HIV-positive.
 
If 7.2 percent of all 40-somethings in America were infected with anything, there would be no other topic of national discussion -- every alarm would ring, every clock would stop. In this case, the victims are geographically isolated, often poor and thus largely invisible.
 
Unity Health Care provides services from dermatology to ophthalmology; due to stigma, few would come to a clinic that deals exclusively with HIV/AIDS. But Dr. Gebeyehu Teferi, the medical director of HIV services, sees the AIDS crisis in every form -- intravenous drug users, prostitutes, men who have sex with men, and middle-aged women shocked by their diagnosis and the infidelity of their partners. (Among African Americans in the District, the single largest method of transmission is heterosexual sex.) "There are late, full-blown cases coming into the emergency room," says Teferi. "People who say, 'I don't use drugs, or even drink.' They forget about the sexual part of it."
 
The staff at Unity recommends three changes to confront the epidemic. First, AIDS needs to be discussed at home. In prevention, there is no substitute for uncomfortable frankness. Neither self-interest nor morality is aided by ignorance.
 
Second, they argue for the "routinization" of AIDS within the range of infectious diseases. Because of its politically charged history, HIV infection is treated differently. A positive syphilis test, for example, is reported directly from the medical lab to the local health department. "If it is syphilis," says Teferi, "there is a knock on their door to get them into treatment. If it is HIV, no one talks to them." Third, testing needs to be broader. At Unity, they refer to HIV status as the "fifth vital sign" (after temperature, heart rate, blood pressure and respiratory rate). People who know their positive status are more likely to change their behavior and get treatment for opportunistic infections. Early treatment can also reduce the virus to a nearly undetectable level in the body, drastically lowering transmission from mothers to children during childbirth and between discordant couples (partners where one is HIV-positive and one is HIV-negative).
 
This raises an interesting prospect supported by Dr. Anthony Fauci, the director of theNational Institute of Allergy and Infectious Diseases. Developing an AIDS vaccine, he says, remains unlikely in the short term. But what if we were to begin treatment with AIDS drugs as soon as someone is diagnosed with HIV instead of waiting, as we now do, until later stages? Lower viral loads would inhibit transmission. "Treatment," he says, "would be prevention." According to the mathematical model Fauci has reviewed, the testing and treatment of 90 percent of those at risk could eventually eradicate -- not just control, but eradicate -- the disease in a geographic area.
 
The obstacles are immense. Would people take AIDS drugs when they still felt well? Would any community help promote testing on such a massive scale? Would it be cost-effective?
 
But even the attempt would have many good effects. It would encourage early care and effective prevention. And if everyone were tested, the stigma surrounding AIDS testing might decrease. It takes only 20 minutes.


v   
 
 
 
 
 
 

[Ann]

Well, this is hardly news. RNA testing has been around for a while now and was approved for diagnostic purposes - when certain criteria are met - about three/four years ago. The "antibody-antigen test" (where a test for the p24 antigen is bundled with the standard antibody test) has also been around for some time now, and in many testing centers it is the test of choice.

RNA testing is very expensive and prone to problems, much more so than standard antibody testing. A positive RNA test must still be confirmed with a positive ELISA and WB - something that will often be showing positive by the time the RNA results come back from the lab anyway. Unless there's been a clear and apparent risk of infection (such as where the partner is KNOWN to be positive), I can't see much benefit to using RNA testing for diagnostic purposes.

And too many people - doctor's included - get the RNA testing confused with DNA testing, which is NOT approved for diagnostic purposes. But invariably, it's the DNA test we see being used (over in Am I).

(And personally, that does my head in. DNA testing isn't approved because it has an unacceptably high rate of FALSE positive results. The results of that happening aren't pretty - the anxiety, the doubting the subsequent negative antibody results... I've seen it happen too many times.)

Please note that this website discusses the various diagnostic tests in the Testing Lesson.

Ann

[veritas]

Perhaps Ann you should send your comments to NATAP ---- since they  did the original reporting.

http://www.natap.org/

I just happen to agree that the earlier one knows their status  the better the planning especially with the newer medications. Please ,don't be stuck in a narrow point of view since therapy is changing rapidly.


v

[Ann]

With p24 testing available (and cheaper), the increased speed with which RNA can diagnose hiv infection is negligible. The benefit of RNA testing is not the quickness of time in which meds can be started, because as I pointed out, a positive RNA test must still be confirmed with a positive ELISA and WB before the patient can be considered well and truly hiv positive. Any doctor who would start a patient on hiv meds before the infection has been confirmed in my opinion is a very irrresponsible doctor. Or on the make. Or both.

The benefit lies in stopping onward transmission. A patient with a positive RNA result can be cautioned that they are likely - but not certain - to be hiv positive and they can be advised to curtail their sexual activities until such time as antibody testing confirms or denies infection.

And for the record, I am NOT "narrow minded" and totally against the early initiation of ARV treatment. It's a personal choice to be made with one's doctor and I fully support anyone's right to start or delay treatment, according to their own needs and beliefs.

Ann
 

[veritas]

 'Any doctor who would start a patient on hiv meds before the infection has been confirmed in my opinion is a very irrresponsible doctor. Or on the make. Or both. "

So I see you don't believe in pre-exposure prophyalaxis. Please tell me your kidding.



"It's a personal choice to be made with one's doctor and I fully support anyone's right to start or delay treatment, according to their own needs and beliefs. "

The same goes for RNA testing. If a patient has the means and wants to test it is their decision.
Please let people know this option exists instead of commiting sins of selective omission.

By the way, did you know that the virus does a lot of damage  in the first 7 to 10 days of transmission before your immune system trys to take over. Ponder that. You can find the study in "Could this be the Holy Grail?" thread.

v

[Ann]

So I see you don't believe in pre-exposure prophyalaxis. Please tell me your kidding.

No, I don't really "believe" in PRE-exposure prophylaxis (except in very specific instances), but I do agree whole-heartedly with POST-exposure prophylaxis when there has been an actual risk. They're two totally different things.

There's a big difference between PEP and initiating meds outside the PEP window frame on the unconfirmed assumption that the patient is hiv positive. PEP is to be initiated no later than 72 hours post-exposure and ideally no later than 36 hours post-exposure. It's designed to stop hiv before it gets started and doesn't usually involve a full triple-drug combo, and it is only taken for 28 days.

What you're talking about is initiating full triple-drug therapy as soon as a positive RNA result is obtained. But what about resistance testing, for example? What about confirming the infection exists and making sure there wasn't a problem with the PCR test? It does happen, you know. Maybe not as often as with DNA-PCR, but it still happens.

The article itself admits that one of the problems with RNA testing is the time it takes for the results to come back - it can easily take up to two weeks. As RNA testing is more likely to show reliable results at ten days than at seven - I can't see many doctors wanting to test at seven only to have to repeat the test a few days later. I can't see how it would be possible to start a patient on a combo they'd been check for resistance against in your 7-10 holy grail time frame. By the time an RNA test comes back (all time told, around three weeks after infection), most patients who have actually been infected will already test positive on either the p24 test or ELISA. Are you starting to see what I mean?

Veritas, the points I have been trying to make are these:

RNA and p24 testing are hardly "news". Not a big or even important point, just a point.

RNA testing has it's place, but it's very limited in it's usefulness. It's also expensive and would be a huge drain on resources to attempt to implement on a large scale.

I can't really agree with your point of: "The same goes for RNA testing. If a patient has the means and wants to test it is their decision.
Please let people know this option exists instead of commiting sins of selective omission.

For someone who has not had a risk or has had a very small risk, the doctor has no business ordering an RNA-PCR test, whether the patient has the means or not. And yes, doctors do this all the time, especially with the DNA-PCR test. Go read the Am I forum sometime and you'll see.

However, where there has been a good likelyhood of transmission occuring (based on the science of transmission, not emotion), then yes, it's an option that should be raised with the patient, along with the information concerning the limits and liabilities of this type of testing. It certainly isn't an option each and every person wanting to test for hiv should be given.

Sometimes I think this attitude of "give them whatever they want, regardless of real need or efficacy" (as long as they can pay out-of-pocket or have good health insurance) in American Healthcare is one of the major things that's wrong with the system. It's got to be one of the things bleeding the healthcare industry dry.

Ann

[freewillie99]

Sometimes I think this attitude of "give them whatever they want, regardless of real need or efficacy" (as long as they can pay out-of-pocket or have good health insurance) in American Healthcare is one of the major things that's wrong with the system. It's got to be one of the things bleeding the healthcare industry dry.

Ann,

That is so true and unfortunately is going to be one of the most difficult things to change in our system.  Frankly I have my doubts.

[veritas]

Ann,

"No, I don't really "believe" in PRE-exposure prophylaxis (except in very specific instances), but I do agree whole-heartedly with POST-exposure prophylaxis when there has been an actual risk. They're two totally different things. "

I'm fully aware of the difference between pre and post exposure. NIAID seems to believe in prep:


http://www3.niaid.nih.gov/topics/HIVAIDS/Research/prevention/research/art.htm

Studies are ongoing.


The CDC also likes the idea:

http://www.cdc.gov/hiv/resources/Factsheets/prep.htm
Some mathematical models suggest that transmission rates could be reduced by 50%. How much is that worth?

Safety studies have already been completed.


"Sometimes I think this attitude of "give them whatever they want, regardless of real need or efficacy" (as long as they can pay out-of-pocket or have good health insurance) in American Healthcare is one of the major things that's wrong with the system. It's got to be one of the things bleeding the healthcare industry dry. "

Those with the means will always have access to the best care no matter what type of Healthcare is implemented.

v

[bocker3]

Those with the means will always have access to the best care no matter what type of Healthcare is implemented.

The most expensive and/or "technologically advanced" -- is not equivalent to the BEST care.  This is what is often lost on folks.

With the logic of doing RNA testing on everyone -- why not just skip the "screening" part and go directly to the confirmatory test -- that would cut some time out too.  I'll tell you why -- it's too expensive and doesn't impact outcomes in any significant way.

But my main point here is that having good insurance or lots of $$ doesn't guarantee the BEST care -- only the most expensive.

Mike

[Ann]

Veritas,

There's not much doubt in my mind that PrEP works on a mechanical/biological level, I'm just not sure it's that great a prevention strategy. But this isn't really the thread to discuss that in and there have been threads in Living where this concept is discussed.

Mike, Freewilly,

I'm glad you guys "get" what I'm saying. Otherwise, I feel like I'm banging my head up against a brick wall.   As you say Mike, the hugely expensive, time-consuming and complicated (thereby increasing the risk of error) RNA test really does NOT have a significant impact on eventual outcomes.

I think society as a whole would benefit more from the promotion of regular, routine hiv antibody testing for EVERYONE, rather than promoting a test that very few are ever going to try to access anyway. Personally, I'd be happier seeing more research money being put into looking at new ways to promote safer sex and regular antibody testing.

Ann

[Miss Philicia]

Personally, I'd be happier seeing more research money being put into looking at new ways to promote safer sex and regular antibody testing.

But basically in the US this is a disease now based on poverty level, race, or sexuality -- shake vigorously with alcohol, crack and meth and there's not much to do with safer sex.  Have you ever tried to open a condom wrapper while balancing a glass stem in the other hand?  Ain't gonna happen.

Call me jaded, but at best you can spend thousands of dollars to put a very small dent in that toxic brew.  Unless you address those underlying issues all of the fabulous RNA tests and glitzy condom posters aren't going to do diddlysquat.

[veritas]

Ann ---- I "get" what your saying ------- I don't agree. Since NIAID and the CDC seems to think there is value in researching this topic, they must see something in it ( like the 50% reduction in transmission of the virus in one of their mathematical models). That will do more than all the posters in the world.

Miss Philicia -----  I fully agree with your colorful observation.

Freewillie ------  I have those same doubts. If you have the means there will always be someone to give you what you want. That will not change.

Mike ---  I agree that the most expensive treatment is not always the best. However, if you have the means, you can have access to the best care (ie: Sen. Kennedy) along with the right advice as to what the best care might be.
As for the expense of the RNA test, like anything else the cost will come down with volume if proven effective in the NIAID and cdc studies.


v

[freewillie99]

Miss Philicia -----  I fully agree with your colorful observation.

Miss Philicia is nothing if not colorful.

[bocker3]

Yes -- having money can allow you to receive better care -- I just wanted to be clear that more costly care does not always equal better.

So, let's say that the RNA test WOULD allow an infection to be detected earlier than the antibody test (and remember just because it CAN doesn't mean it DOES in all cases).  How is this going to help reduce the more likely source of infection -- having unprotected sex with someone who doesn't know their status, assumes they are negative and has no intention of getting tested regardless of the method?

A screening test is supposed to be relatively inexpensive -- to avoid the unnecessary (and expensive) confirmatory testing.  Generally a screening test is set up to skew more toward false positives -- in order to minimize missing people who actually have the condition being tested for -- think RPR test for syphilis before an anti-treponemal test -- the problem with HIV is that there is that window period, so on the face of it, earlier detection by a different method would be beneficial.  However, if the cost is greater than the benefit (in this case the benefit is in actually identifying significantly MORE true HIV cases) than why go to the more expensive screening test.

Finally -- just because research is being done and showing "good" results, does not mean the researchers are truly advocating it's adoption.  There is a strong push for scientist to PUBLISH -- showing something works in theory (i.e. mathematical models) or even in small studies, does not mean it will work similarly in the real world.  However, it does get the scientist published.

Again -- bottomline is does this extra cost result in real world improved outcomes?

I think it would be a much better investment to get more people to test with current technology.

Mike

[veritas]

Mike,

Your questions are answered in the above post:

"This raises an interesting prospect supported by Dr. Anthony Fauci, the director of theNational Institute of Allergy and Infectious Diseases. Developing an AIDS vaccine, he says, remains unlikely in the short term. But what if we were to begin treatment with AIDS drugs as soon as someone is diagnosed with HIV instead of waiting, as we now do, until later stages? Lower viral loads would inhibit transmission. "Treatment," he says, "would be prevention." According to the mathematical model Fauci has reviewed, the testing and treatment of 90 percent of those at risk could eventually eradicate -- not just control, but eradicate -- the disease in a geographic area."

Also, anyone engaging in unprotected sex without having himself tested in this day and age, certainly, is
foolish.


"A less expensive alternative to the RNA test may not be far away. The centers recently began a study to compare RNA testing with an advanced version of the standard test, which is easy to administer and can detect a substance produced by the virus in its early stages."

The RNA model has already been helpful.

v
 

[veritas]

Needful things !

"Although vaccines will continue to play a prominent role in NIAID’s broad and multifaceted HIV prevention research agenda, other new prevention approaches are in advanced testing. These include microbicide gels or creams that can be applied prior to sexual intercourse, and pre-exposure prophylaxis—the use of antiretroviral medicines in people who are not infected with HIV but who are at high risk for infection "  -------- Tony Fauci

http://www3.niaid.nih.gov/about/directors/news/hvad_09.htm

v

[RapidRod]

Use a condom and you don't have to worry about side effects. Way cheaper than pre-pep meds.

[madbrain]

Use a condom and you don't have to worry about side effects. Way cheaper than pre-pep meds.

Yes, condoms are cheaper and have less side effects than PReP certainly. But how effective is PReP ? I think it's a question that deserves an answer.

Condoms have a non-zero rate of failure. They sometimes break or slip. What's the rate of success/failure for PReP ? If PReP turns out to be 100% protective against infection, then potentially one might want to use it instead. Or even using both condoms and PrEP to reduce risk, if PReP alone doesn't do it. I don't think we should turn our back on new methods of protection. If PReP becomes popular, its cost should hopefully go down. If a PReP regimen is using old HIV meds with expired patents, it could even cost about the same as condoms in the future.

[Inchlingblue]

  If PReP becomes popular, its cost should hopefully go down. If a PReP regimen is using old HIV meds with expired patents, it could even cost about the same as condoms in the future.

yea but who wants lipoatrophy and all those other nasty things that can possibly arise with the older drugs with expired or expiring patents..besides most of the research has pointed to Tenofovir as the ideal candidate for PrEP, and there's a new study that indicates it does not have to be taken every day....other possible good candidates fror PrEp are the new entry inhibitors (Selzentry), the idea is to get to the virus before it has a chance to even enter cells

there's an excellent website www.prepwatch.org with information about all things PrEP

[bobino]

Even assuming PrEP is effective, who's going to pay for it?  I seriously doubt insurance companies are going to pay for expensive medications for perfectly healthy people.  We can barely get them to pay for meds in those that are truly sick.  I think that financing will be the biggest problem.

[Inchlingblue]

Even assuming PrEP is effective, who's going to pay for it?  I seriously doubt insurance companies are going to pay for expensive medications for perfectly healthy people.  We can barely get them to pay for meds in those that are truly sick.  I think that financing will be the biggest problem.

It's a good point but part of what's being studied is not only does it work as far as preventing infection but what are the economic implications of that. Some of the mathematical models have shown that if it does in fact work it could be cost-effective when compared to "x" number of people getting HIV and having to take HAART for life (not to mention all the other health expenses for someone who is HIV+), it could actually be a lot cheaper to take PrEP.

Insurance companies and local/state/federal governments would be inclined to pay for it if convinced it works. And of course, the people who would go on it would be those in "high risk" groups such as men who have sex with men, not the general population. With more people on meds it could also bring prices down on some of them.

[RapidRod]

PrPEP will never be as cost effective as a condom.

[madbrain]

Even assuming PrEP is effective, who's going to pay for it?  I seriously doubt insurance companies are going to pay for expensive medications for perfectly healthy people.  We can barely get them to pay for meds in those that are truly sick.  I think that financing will be the biggest problem.

Insurance companies don't pay for condoms either, people do.

[bocker3]

Mike,

Your questions are answered in the above post:

"This raises an interesting prospect supported by Dr. Anthony Fauci, the director of theNational Institute of Allergy and Infectious Diseases. Developing an AIDS vaccine, he says, remains unlikely in the short term. But what if we were to begin treatment with AIDS drugs as soon as someone is diagnosed with HIV instead of waiting, as we now do, until later stages? Lower viral loads would inhibit transmission. "Treatment," he says, "would be prevention." According to the mathematical model Fauci has reviewed, the testing and treatment of 90 percent of those at risk could eventually eradicate -- not just control, but eradicate -- the disease in a geographic area."

Sorry that I haven't replied, but I've been on vacation.

Here goes:

While I agree that this sounds reasonable -- a mathematical model does not necessarily guarantee that it will work in the "real" world.  A model is a best guess.  Plus, how in the world will we ever get 90% of those at risk to test with the new test when we can't get them to do so with the current one.  So, again, it sounds, theoretically feasible, but I daresay that it is a model that does not take in to account human nature (which is where many models breaks down).

Also, anyone engaging in unprotected sex without having himself tested in this day and age, certainly, is
foolish.

And yet the infections continue unabated.....  this statement really is one that simply tries to overlook the true issue here.  People have unprotected sex, people refuse to be tested, people refuse to believe that they are at risk, people assume others are negative (as well as they themselves).  These are the reasons that the epidemic continues -- and testing those who do decide to test by a method that might detect an infection earlier is likely to have limited value.

"A less expensive alternative to the RNA test may not be far away. The centers recently began a study to compare RNA testing with an advanced version of the standard test, which is easy to administer and can detect a substance produced by the virus in its early stages."

The RNA model has already been helpful.

v

So, the RNA test may indeed become less expensive over time -- many assays do.  However, that will only happen if more of them get ordered and that is unlikely to happen if the increased costs don't get leveled out by a significant increased benefit (that is a real world benefit, not a theoretical one).  Before this could happen, we really have to figure out how to get more people to get tested. 

It would be interested to see how this model would predict the decrease in transmission if 90% of those at risk actually got tested with the current test!!  I bet it would also predict a huge drop in transmission -- now if we could just get that 90% to actually test.

Mike