Category: Perspectives

Happy Twenty twenty too?

In many ways the 2^nd year of the COVID19 pandemic was supposed to be better – we had vaccines, new antiviral drugs in the pipeline, monoclonal antibodies and it felt like things would finally get back to normal. The arrival of Omicron in late November 2021 dealt a big blow to these hopes sweeping across the world with lightning speed, leaving chaos and uncertainty in its wake. The new variant of concern (VOC) first identified by scientists in Botswana and South Africa has seen some European countries reinstate lockdown measures, and the United States grapple with upscaling access to rapid diagnostic testing and increasing vaccine uptake.

At the start of this new year 2022, things feel a bit depressing. We all seem resigned to being the next person with a sore throat and that tell-tale dry cough anxiously watching the double lines to appear on a rapid test. Would this year be better? Will we finally learn the lessons the virus has desperately tried to teach us these past two years?

It didn’t have to be this way. From the beginning of the pandemic the threat of new variants of SARSCoV2 had always loomed. This justified the urgency to share vaccines and other resources globally to stay ahead of the virus. “No one is safe until everyone is safe” became the mantra of global health equity advocates everywhere but ignored by those who had the power to do something about it. The legacy of the what was supposed the year of celebrating scientific innovations to end a global pandemic is one of stark division pitting the wealthiest against the most vulnerable.

Promises Not Kept – Vaccine Equity 

There are 28 vaccines against SARSCoV2 authorized and in use globally. 3.77 billion people have received at least two doses of vaccine. A veritable feat considering that the first vaccines were authorized barely 12 months ago. The rollout of vaccines has been plagued by waning effectiveness against infection, emergence of immune escape variants of the virus, vaccine hesitancy and the failure to deliver on the promise of vaccinating the world. 3.3 billion people mostly in low-income countries are yet to receive a first dose of any vaccine. The main driver of global vaccine inequity the has been the hoarding of available vaccine doses by rich countries purchasing more than needed for their populations. The prospect of intellectual property waivers to ease technology transfer and increase vaccine production in (LMIC) has faded. Key players like Germany have opposed the strategy and stifled negotiations. 

All of these factors have been compounded by the need for vaccine booster doses which have increased the pressures on supply and further widened the vaccine accessibility gap. The future of vaccine equity remains uncertain in 2022. Will we see updated second generation vaccines as the older versions become less protective against new variants? Would updated vaccines be available to everyone or will poor countries be left be to rely on older less-effective vaccines? Can global leaders commit to breaking the damaging cycle of vaccine tiering and hoarding? The answers to these questions are known.

It is clear that repeating the mistakes of 2021 is reckless and unlikely to yield different results. Without expanding the capacity of vaccine production in LMICs, the flow of vaccines will remains skewed towards HICs. Distribution of third vaccine doses in the most vaccinated parts of the world currently exceeds first doses in LMICs. Complacency has set in and the chatter about 1st doses before 3rd doses has died down. This doesn’t make the millions of people yet to get their first shots magically disappear but guarantees the virus continued opportunities to spread.

Innovations Not Shared – Monoclonal antibodies, Immunomodulators and Antivirals 

When it comes to therapeutics, we are in a better place starting the new year than 12 months ago. Unfortunately, the scientific progress in the treatment of COVID19 has also been plagued by inequity. Monoclonal antibodies have been a live-saving intervention for millions of people in wealthy countries but beyond reach for poorer countries due to their high cost and the challenges of delivery. Immunomodulatory therapies haven’t fared any better. Dexamethasone is still the sole option in many resource-limited settings despite multiple mortality reducing options.

The end of 2021 brought renewed hope with the authorization of oral antiviral drugs from Pfizer and Merck. High demand and limited supply mean that these drugs may only trickle down to LMICs several months from now. Ideally, countries with fragile health systems, unable to provide a high level of care for severe COVID19 should be prioritized for oral therapies which slow disease progression and keep patients out of hospital. This is unlikely to happen as has been the case with vaccines. Pharmaceutical companies have signed contracts to manufacture lower priced generic versions of these antiviral treatments. However, ramping up supply will take time and limited doses have been secured through advance purchase contracts by high income countries.

Africa’s Third Pandemic Year 

Africa bears the biggest burden of the inequity in accessing vaccines and therapeutic resources for COVID19. Only 9% of the continent’s population is vaccinated. This falls short of the 40% goal set by the WHO at the beginning of 2021. Limited health infrastructure, unsteady vaccine supply, transportation and storage challenges have all contributed to low rates of vaccination. 

Vaccine doses delivered with short expiration windows have led to only about 63% of the vaccines delivered to the continent being utilized. Furthermore, misinformation has fueled a loss of confidence in science and vaccines resulting in low uptake by the population even in countries where vaccines are available. The emergence of a vaccine tier system has not helped. A significant proportion of vaccines donated through COVAX are vectored vaccines from AstraZeneca and Johnson and Johnson, both of which have been plagued by rare blood clotting adverse effects. These vaccines have essentially been phased out of use in Europe and North America with mRNA vaccines being the preferred option. Many on the continent have viewed with skepticism and suspicion being offered vaccines which albeit effective are no longer used in the high-income countries donating them.

Africa compared to other parts of the world has seen fewer cases and deaths directly from COVID19. Many view the pandemic as of a less pressing health concern than Malaria, HIV/AIDS, Tuberculosis and other poverty related issues. The impact of COVID19 has been devastating for every aspect of healthcare and the economy in Africa. However, it is challenging to articulate secondary benefits of vaccination in public health messaging without addressing immediate pressing concerns.

With new vaccines now authorized and COVAX finally able to increase its supply, it is likely that in 2022 supply will exceed demand and the bigger challenge will be getting the available doses in arms. This will require addressing logistic challenges and barriers to vaccine delivery but also tackling head on the real issues around vaccine hesitancy and acceptability. While the mantra of “vaccinate the world” is attractive, one size will not fit all. A more tailored approach with countries setting realistic targets for their populations is likely to be more acceptable.

The Show Must Go On – AFCON with Omicron surging 

Africa has weathered previous waves of SARSCoV2 successfully but the combination of Omicron surging, low vaccination rates and the African Cup of Nations (the continent’s largest sporting event ) brings fresh concerns. For a continent that loves its football, cancelling the competition for a second time was not on the cards. Cameroon will host and many see the success of the Olympics as proof that this can be done safely. However, the conditions in Cameroon leading up to the AFCON are quite different. 

Cameroon is among the lowest vaccinated countries in the world. Non-pharmacologic interventions are barely enforced and pandemic is high. The competition will proceed with stadia at full capacity unlike the Olympics where no spectators were allowed. The ministry of health has announced that proof of negative testing and vaccination for entry into stadia. These measures are encouraging but corruption and bribery are rife and it is doubtful how these measures would be enforced. Also vaccine hesitancy is prevalent and testing capacity is low.

As a Cameroonian and a football fan I am rooting for a successful celebration of African football. I hope the resulting surge of COVID19 cases is minimal. The economy of the country needs the boost and the continent needs joy and celebration that accompany the AFCON. However, this hope is tempered with perspective. With omicron we are dealing with the virus in its most infectious variant yet. While the show must go on, the consequences of a massive wave after the games could have significant regional impact.

Despite encouraging signals that omicron may cause less severe disease, a rapid rise in case numbers can be a major stress test for any health system. This has been demonstrated across Europe and North America. The youthfulness of the population in Cameroon (median age 17) and immunity accumulated from previous waves may mitigate the severity of a surge. Only time will tell the impact of the games of the trajectory of the pandemic in Cameroon and Africa. Another situation to watch closely at the start of this new year.

The Virus is Still Speaking – We Should Start Listening

For many the realization has set in that we have to learn to live with the virus. How we choose to do that matters. The start of new year is always an opportunity for a reset and learn from past failures. With COVID19 this means a renewed commitment to global solidarity, not only in words but in action. The approach of every country for itself saw us squander the potential of vaccines and therapeutic advances in 2021. The virus carried on, unperturbed leaving a string of new variants, long-term chronic symptoms and deaths in its wake.

We get a chance in 2022 at a do over, this time with even more tools in the pandemic toolkit. That means living out the words “no one is safe, until everyone is safe” by holding world leaders accountable to end the pandemic. Every moment wasted in repeating old mistakes is another victory for the virus. The virus will keep speaking until we are ready to listen and respond accordingly. That’s our only hope to make this year a better one for us all. 

Abbreviations: LMIC – low and middle income countries, HIC -High income country

Written by Boghuma K. Titanji

Winter is coming… 

As we head into the winter months in the northern hemisphere, the COVID-19 pandemic continues to dominate international news headlines. After a brief dip in case numbers in parts of Europe and the United States this summer, the turn of the weather heading into the colder months has brought with it a new surge of infections plunging many countries into their second and third waves. France and Germany have imposed lockdowns and curfews in an attempt to curb outbreaks spiraling out of control within their borders. Belgium is facing severe shortages of healthcare staff in its hospitals with intensive care beds set to run out in a few weeks. The United States, facing a dearth of coordinated national leadership, continues to see uncontrolled outbreaks in many states. 

Disaster avoided? 

Sub-Saharan Africa on the other hand has to a large degree defied the predicted apocalypse that followed the first reported case of COVID-19 on the continent back in February. News headlines early on were quick to highlight the continent’s weak health systems, fragile infrastructure and limited access to medical supplies and advanced medical equipment. Melinda Gates with great foreboding in April, made a dire prediction in an interview of “dead bodies on African streets soon”. These predictions fortunately have not come to pass as the African continent has consistently recorded the lowest numbers of cases and deaths from COVID-19 globally. As of October, 29^th 1,750,331cases and 42,175 deaths (0.1% of deaths globally) from COVID-19 had been reported on the African continent which is home to 13% of the world’s population. 

Big wins but more to do

Due credit has been given to a robust public health response by local governments with the support of WHO and Africa CDC . These organizations worked in tandem to improve testing capacity and implement measures which helped slow the initial spread of the virus on the continent. These measures were largely supported by populations accustomed to dealing with outbreaks of infectious diseases and tapped into good community health systems strengthened by previous epidemics.

Ongoing speculation on the protective benefits of a warmer climate, a more youthful population and lower prevalence of risk factors for severe COVID-19 prevail. These theories bring with them the risk of complacency and premature victory laps in the wake of successes recorded in the first wave. The surge in COVID-19 cases across Europe and the Americas is slowly beginning to reflect as an upward trend in new cases in Africa. Whether this will result in a true second wave or a quiet smolder remains to be seen. Regardless of what happens in the coming months, the pandemic is far from over and the efforts to contain it must not relent.

Consolidating an initial good response 

As SARSCoV-2 has spread globally over the past 10 months our knowledge of the virus and how to control it has also grown at an incredible pace. There has been progress in therapeutics and several vaccine candidates are in advanced stages of development, with hope of starting distribution by early 2021. The access to these advances is expected to vary by region with poorer countries unlikely to access advanced therapies and vaccines until much later. Tried and true public health approaches have to remain at the center of the pandemic response in low income countries, but pandemic fatigue and the economic implications of strict enforcement present considerable challenges to sustaining these efforts long-term.

Social distancing, mask mandates and lockdowns

Many African governments took an almost draconian approach in enforcing adherence to strict lockdowns, travel restrictions and mask mandates. In Kenya aggressive policing to uphold COVID–19 curfews led to several weeks of violence and up to 15 deaths. In Senegal where civil uprisings are rare, the initial lockdowns in March sparked violent clashes between the population and the police. These lockdowns have quickly translated to significant losses in income for small businesses and daily wage earners, plunging many deeper into poverty. In recent months a lot of these measures have been loosened in an attempt to ease the economic toll of the pandemic on the population. Without robust and sustained government financial support moving forward, it is hard to imagine any appetite on the part of local populations to return to these strict measures even as fears of a second wave of infections loom. Some African government have provided stimulus packages for economic relief to their populations but these have been modest and do not meet the widespread need.

Social distancing and isolation of those who test positive haven’t been without challenges especially in large and densely populated cities . Government structures dedicated for quarantining purposes have been largely under-utilized due to the stigma associated with carrying a diagnosis of COVID-19. The models adopted in western cities such as working from home, online shopping, and grocery shopping on a schedule to limit person to person interactions is simply not feasible or adaptable to many African countries.

“A large share of Africa’s urban population lives in crowded informal settlements, with small one- or two-bedroom houses. Differences across the continent are large, but on average, 45% of households share toilets with their neighbors and for 17%, their only access to water is from a communal tap“. There is a need to develop innovative strategies for infection control which take into account unique characteristics of the environment and provide the population with the means to comply to these measures without jeopardizing their livelihoods.

Therapeutics

Remdesivir, has become the first antiviral drug approved for the treatment of COVID-19 in the United States.  This drug largely owes the initial phases of its clinical development to studies done in patients in the Democratic Republic of Congo (DRC) during the 2018 outbreak Ebola Virus Disease (EVD). While debates on the true efficacy of Remdesivir for COVID-19 continue to polarize, it is unlikely that the severely limited worldwide supply will trickle into enough African hospitals to create any meaningful impact on patient outcomes. 

Monoclonal antibodies, another treatment strategy are likely to gain emergency use authorization for treatment on non-hospitalized patients with COVID-19 in the USA, in coming weeks. This therapeutic approach gained significant popularity during the last outbreak of the EVD in the DRC with two monoclonal antibody therapies showing statistically significant mortality benefit in clinical trials of acute EVD. The benefits so far  reported from trials of monoclonal antibody therapies in COVID-19 are  modest and these treatments carry a prohibitive price tag limiting their availability for now to very wealthy countries.

The RECOVERY trial, from the UK, demonstrated the benefit of a cheap steroid Dexamethasone in reducing mortality from severe COVID-19. Dexamethasone is on the WHO essential medication list which means that it can be accessed even in the most remote health settings. Dexamethasone has quickly become an important tool for treating COVID-19 patients globally. Widespread use of steroids isn’t without risks especially in areas with concomitant high prevalence of other infectious diseases which can be made worse by steroid use e.g. Tuberculosis, viral Hepatitis and certain parasitic infections etc. There is need for local prospective studies to better define the role of steroid therapy in treating COVID-19 in Africa taking into account unique risks they portend in this setting.

Vaccines

A lot hope for returning to a normal life now hinges on an effective COVID-19 vaccine. Several promising candidates have been fast tracked through phase1,2, 3 clinical studies. If these vaccines clear the threshold for efficacy, the bigger task ahead will be their distribution to the world’s 7.8 billion inhabitants.

Wealthy countries have positioned themselves ahead of the line by making deals worth billions to secure vaccine doses from leading manufacturers. The COVID-19 Vaccine global access (COVAX) initiative led by the WHO, the Coalition for Epidemic Preparedness (CEPI) and the Global Vaccine Alliance (GAVI) is working to ensure equitable access and distribution of vaccines between wealthy countries and middle- and lower-income countries. While this initiative is welcome and laudable, history from recent outbreaks gives Africa many reasons to worry.

In 2004, during the outbreak of the avian flu (H5N1), negotiations led by the WHO to share stockpiles of vaccines rapidly broke down. This scenario was again replayed in the 2009 H1N1 outbreak during which wealthy countries again reneged on their promises to share vaccine stockpiles and hoarded doses for themselves. In the mid-nineties antiretroviral therapies for treating HIV were priced out of the reach of many African countries and created delayed access to life-saving treatment for many people living with HIV. It is estimated that between 1997-2007 at least 12 million Africans died from HIV due to inability to access life-saving treatment. In the early months of the COVID-19 pandemic, many African countries were frozen out of the global market and struggled to secure personal protective equipment and testing supplies crucial for the pandemic response. The Africa CDC estimates the cost of building infrastructure and delivery systems to distribute a COVID-19 vaccine on the continent between $7 billion and $10 billion, a target which is a long way from being met.

On a more positive note COVID-19 vaccine trials are now recruiting participants in up to 6 African countries. A key piece to successful vaccine distribution and fighting growing vaccine hesitancy is demonstrating efficacy in local populations.

Far from Over

Whether we see subsequent waves or a more smoldering course of COVID-19 in Africa is anyone’s guess. Regardless of the scenario that emerges, the most vulnerable amongst us will suffer most and longest. As we continue to fight this pandemic a global response in its true sense must remain grounded in our shared humanity. Africa being relatively spared in the first wave of the pandemic is a deceptive narrative that threatens the longterm sustained response. A slow and prolonged outbreak in Africa may present an even bigger challenge as this is likely to extend the devastating impact on the economy, education and healthcare well beyond this pandemic.

Written by : Boghuma K. Titanji

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It’s 6:30 am on a Saturday morning and as has become my daily routine, I grab my phone and search the internet looking for updates on the 2019 novel Corona virus outbreak (nCoV-2019). Today it is dominated by the news of the United States imposing a limited ban on travel from China and on foreign nationals who have visited the country within the past 14 days. A few other countries including the Bahamas, Mongolia and Singapore have adopted this approach, also imposing limited and full travel bans from China. 

A New Decade, A New Pandemic?

A silent moment of reflection brings back flashbacks from another time and another outbreak. In 2013-2014 during the peak of the Ebola outbreak in West Africa, as West African living in London, I experienced first-hand the impact of a travel ban. Such bans quickly breed stigma and xenophobia towards large groups of people and also negatively impact the outbreak response. Since the first cases of an unusual respiratory illness were reported in November 2019, what’s now being dubbed novel Corona-virus 2019 (nCoV-2019) has recorded almost 12,000 cases and caused over 200 deaths. 98% of the cases so far have been in mainland China with exported cases reported in 26 countries around the world – a number that most certainly will continue to grow. 

The scientific and medical communities have presented an incredibly united front with a pace of discovery and information sharing exceeding anything we have seen before. We now have a better understanding of how the virus is transmitted, the symptoms exhibited by those who become ill from it and drug trials are underway studying possible treatments. The nCoV-2019 outbreak highlights how interconnected our world truly is but also exposes the stark inequalities that make it wholly unprepared to fully combat a true pandemic.

Wealthy and powerful nations have rushed to extract their nationals from Wuhan province in China, and flaunted elaborate and “full proof” plans for quarantine at home. Resource limited countries meanwhile, nervously await that first returning traveler with a nCoV-2019 diagnosis and plan as best as they can on how they will respond when that time ultimately arrives.

Travel bans – Deceptive, ineffective and morally wrong 

The World Health Organization earlier this week declared the nCoV-2019 outbreak a global health emergency. A move that is designed to help a more coordinated international response to the outbreak. In that same announcement it also urged nations to not restrict travel or trade with China – a plea that may have fallen on deaf ears. At face value travel bans may seem like a reasonable approach, as governments and politicians face intense pressure to “do something”. In reality these bans are ineffective, cause significant downstream effects and impede on an effective response. There is an immediate and significant economic impact on the most affected regions, high cost associated with crafting and implementing travel restrictions and a direct effects on transparency in reporting on the outbreak as countries fear they may be the next victim of future bans.

An unleveled playing FIELD

One of the key principles of the International Health Regulations (IHR), a legally binding instrument of international law with 196 signatory countries, is the emphasis on avoiding “unnecessary interference with international traffic and trade”. In practice this means that individual states may not impose travel bans in the absence of a WHO recommendation or scientific evidence. The United States as the world’s leading super power, through the current ban has the ability to severely erode these regulations and global collaboration in the face of the ongoing nCoV-2019.

A set of rules that seemingly only applies to weaker and resource challenged countries disincentivizes future sharing of surveillance data to predict and curb future outbreaks. Lower income countries are likely to question the benefits of sharing surveillance data and being transparent on how they report on outbreaks when more powerful signatories to the IHR openly violate their own commitments to the same regulatory documents.

The toll of Ebola on West Africa

The West Africa Ebola outbreak lasted 2.5 years and affected 30000 people. Almost 7-years later countries most directly impacted (99% of cases were in Guinea, Sierra Leone and Liberia) have not fully recovered from the effects of the airline freezes and travel bans imposed during that time. The resulting “loss” of direct travel and tourism GDP is equivalent to 0.9% and 1.6% of the whole economy in Guinea and Sierra Leone respectively. These are losses that the most fragile economies and healthcare systems in the world absolutely cannot afford and leaves then highly vulnerable to outbreaks like nCoV-2019. Canada a country with a strong economy, suffered indirect and direct losses estimated at 2-billion dollars in 2002-2003 during the outbreak of the Severe Acute Respiratory Syndrome (SARS) as a result of a WHO-imposed travel ban. These lessons from the recent past should help shape a global response that supersedes the short sighted interests of individual nations.

Blame it on bat soup? – Challenging Stigma and Xenophobia in the face of an outbreak

As we grapple with this outbreak many Chinese people around the globe are having to deal with xenophobic and racist chatter about their eating habits.  This is reminiscent of the several media reports on “rampant” bush meat consumption in Africa during the West African Ebola outbreak and how this may have triggered the start of that outbreak. As someone born and raised in the African country of Cameroon, a warm plate of bush meat stew accompanied with boiled ripe plantains evokes warm memories of home and a lifestyle that I grew up with. Not the guilt and shame that a false narrative would have me feel about how Africans and their love of bush meat may be fueling outbreaks of zoonotic diseases.

When faced with the unknown the instinctive human reaction is usually, seeking to assign blame and point to the other. While this may offer a sense of superiority to the one doing the finger pointing it is highly damaging to the targeted group and sows the seeds of stigma and xenophobia which often outlast any outbreak. The WHO in avoiding linking a city, region or country to the naming of the new virus has been prescient on the negative impact this would have had on the residents of Wuhan. nCoV-2019 may not roll off the tongue as easily as some would like but at least spares the residents of Wuhan a haunting label they may never be able to shake-off after the outbreak is long forgotten. At a time when the global community must unite to face a pandemic being sensitive and compassionate in how we react to this outbreak is crucial.

More Connected, More United

 

We are only seeing the tip of the iceberg, this outbreak could last several more months, with projections that thousands more will become infected . While the scientific community comes together to find effective treatments and a vaccine, governments must recognize that we are all in this together. Faced with an impending pandemic travel bans, stigma, xenophobia and racism have no place in the appropriate  moral response. We are all in this together and how we react in the coming days and months must reflect this.

Written by : Boghuma. K. Titanji

For reliably sourced information and updates on the outbreak I recommend visiting the Infectious Disease Society of America (IDSA)website at – https://www.idsociety.org/public-health/novel-Coronavirus/

Descovy for PrEP …excluding cisgender women 

Earlier this month the US Food and Drug Administration (FDA) released a statement approving the use of Descovy for pre-exposure prophylaxis (PreP) to prevent infection with HIV. This announcement shockingly excluded cisgender women. Descovy is only the second drug approved for HIV prevention alongside its better-known counterpart Truvada which has been approved for this purpose since 2012. The news was received with shock by HIV/AIDS advocates and the medical community at large. The drug’s maker Gilead, only tested its efficacy in men and transgender women, and as such the US F.D.A claimed that a recommendation could not be made for its use in cisgender women/individuals engaging in receptive vaginal sex. 

This announcement highlights a pattern in which women are excluded in important studies of new medications and interventions targeting HIV prevention and treatment. UNAIDS set at ambitious target to end the AIDS epidemic by 2020 called 90-90-90. This means 90% of all people living with HIV(PLWH) will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. While many have lauded this aggressive push towards ending the epidemic, we are far from achieving this goal which will remain unattainable if women continue to be excluded in important studies on treatment, prevention and potential cure strategies for HIV.

Unique Challenges and Pattern of Neglect

Women represent half of the adults living with HIV worldwide and 70% of PLWH in sub-Saharan Africa. HIV and AIDS remain the leading cause of death in women of reproductive age and infection rates in young women aged 15-24 are twice as high as in young men of the same age group.  Despite these stark numbers, women are severely under-represented in clinical trials on HIV treatment and prevention – accounting only for about 19% of participants. 

This pattern unfortunately is not new because including women in HIV clinical trials presents unique challenges that researchers have historically not been equipped or prepared to fully address. Women of reproductive age can become pregnant which in itself becomes a barrier to entering certain clinical trials. Furthermore, women often bear most of the responsibilities of childcare and other family related commitments. Disadvantaged women living in poverty, adolescent women and women living sub-saharan Africa represent vulnerable groups disproportionately affected by these factors. This implies that they are more likely to miss follow-up visits required by clinical trials and to drop out of studies before completion even when they are included. 

This has resulted in limited information on the safety of most HIV drugs in pregnancy and a limited understanding of how gender specific physiologic and genetic factors may affect the body’s immune response to the virus. The most significant implication of this in my view is we may be failing to offer women the best data proven interventions for HIV prevention and treatment targeted to their unique needs.

Equity and Access

In addition to the unique challenges of HIV research in women, there are also significant barriers and challenges to accessing those interventions which have proven to be beneficial. A good illustration of this are the challenges faced by the roll-out of the potent antiretroviral agent Dolutegravir, for women of childbearing age in sub-Saharan Africa. 

Compared to older antiretroviral drugs, Dolutegravir controls HIV more rapidly and is associated with fewer side effects. In 2017 a generic one pill a day antiretroviral cocktail of three drugs including Dolutegravir became available for just 75$ for a year’s worth of treatment. This development meant that millions of PLWH in Sub-Saharan could finally have access to a state of the art first line treatment for HIV at a cost that was more affordable than the older less well tolerated drugs. 

Dolutegravir and the Right to Choose

In May of 2018, just as governments in the region were planning on including Dolutegravir into national treatment guidelines, a study in Botswana reported some concerning findings. Among 596 children born to women with HIV who received Dolutegravir during the first trimester of pregnancy, they noted an increased number of children born with neural tube defects (0.7%) compared to women who received older antiretroviral drugs (0.1%). A larger study presented at the IAS (International AIDS society) meeting in June 2019 estimated an associated risk for neural tube defects of about 0.4% with Dolutegravir but conceded that more data is needed. 

These concerns surrounding the use of Dolutegravir in pregnancy slowed its rollout with many governments debating whether women of reproductive age living with HIV should be given access to this drug. This led to a powerful consensus statement by female HIV activists in the region  stating “Each woman, is not just a vessel for a baby, but an individual in her own right, who deserves access to the very best evidence-based treatment available and the right to be adequately informed to make a choice that she feels is best for her.”

A simple solution to ensuring that women can safely access and benefit from Dolutegravir while we await more definitive information on its safety in pregnancy,  is providing women with HIV access to contraception and pregnancy termination services. This in itself is fraught with controversy and opens the broader conversation of  how a woman’s right to choose what happens to her body and her health is inextricably linked to our ability to fully address the HIV epidemic in this demographic. 

On the issue of PrEP Access and Women

Pre-exposure prophylaxis with a combination of two antiretroviral drugs in a single pill, is the only effective strategy proven to prevent HIV infection. The roll-out of this intervention is unfortunately another area in which women have experienced unequal attention. In the United States besides black, hispanic and white MSM (men who have sex with men), black women are the largest group at risk for HIV infection. In 2017, 4008 new HIV infections in the United States occurred in black women yet many have never heard of PrEP or how to access it. 

From a broader perspective about 1.1million Americans are at high risk for HIV and could benefit from PrEP according to the CDC . However only about 10,000 women of any race are using the pill to prevent HIV. Excluding women from access to the latest drug (Descovy) approved from PrEP only compounds these existing inequities.

Young women in sub-Saharan Africa represent 3 million of the 4 million PLWH aged 15-26 years in the region. Ongoing studies on PrEP usage in this vulnerable group indicate that while many (95%) are willing to take PrEP, sustained adherence to the intervention is a challenge. Only 9% of young women are shown to have drug levels in their blood associated with high adherence at 12 months after being enrolled into PreP programs. This suggest that young women in Sub-Sharan Africa may have unique PrEP adherence support needs which would need to be studied and addressed in order to fully utilize this prevention strategy. 

Leave no Woman Behind 

I am currently taking care of Anna in a clinic in Atlanta. She is a 30-year-old black woman who was recently diagnosed with HIV and AIDS during her pregnancy earlier this year. Fortunately, her baby was born healthy but Anna is fighting for her life after presenting with very advanced disease and several complications. During her most recent visit to the clinic, I prepared a pill tray with the 15 pills a day she is expected to take to treat the multiple infections ravaging her body and to control the HIV.

 Before coming to the clinic, Anna had never heard about PrEP and did not have access affordable birth control. She is often teary with worry that she will not survive this phase and may not live to see her children grow up. This is what being left behind looks like – missed opportunities for prevention, late diagnoses and complications of AIDS.

Every minute around the world, more than two women will become newly infected with HIV and one of those will be under 18. This will only change if we are more deliberate in prioritizing HIV research that includes women. Getting to zero, means leaving no one behind. When it comes to women and HIV epidemic, we are doing just that.

*Names and specific patient identifiers were modified for this article to preserve patient anonymity.

*Access outbound links to references by clicking on the underlined text.

Written by: Boghuma K Titanji

“I sleep with my hands in my pants”

On what seems like an ordinary Saturday call, I get a late afternoon page from the ED. It’s a young man presenting with “weird” lesions on his scalp. The emergency doctor wants to treat for syphilis but is not sure quite sure of the diagnosis and calls the ID consult team for help. I go to see the patient, a pleasant otherwise healthy 20-year-old man. He is visibly worried about the multiple unusual lesions on his scalp which appeared about a week ago. The lesions have a classic wet wart-like look of Condyloma lata, a classic genital rash seen in secondary syphilis. But why did they appear on his scalp?

With the initial pleasantries of the history taking out of the way I take a deep dive into the sexual history. It turns out the patient has had some recent unprotected casual sexual encounters with partners he met online, and is clearly at risk for sexually transmitted infections. A thorough physical exam reveals a similar rash on the patient’s genital area. My immediate thought is the lesions on his scalp are likely the result of   self-inoculation from groin lesions. Like any ID physician would, I ask even more strange questions and get the answer that confirms our hypothesis, “I sleep with my hands in my pants, it’s just something I’ve always done”. 

Mystery solved! I recommend empiric penicillin for presumptive treatment of secondary syphilis, which will be confirmed on his blood test results a few days later. I provide a well-rehearsed spiel on safer sex practices. The patient visibly shaken by an STI diagnosis, in the moment, is self-berating over recent choices he has made “hooking-up” casually with strangers from the dating apps in his phone. I nod in empathy with his moment of tinder regret and provide reassurance that his infection is curable and he will be fine. Months from now this whole episode will be a distant memory, but will he have the courage to swipe right again? Is the blame he is placing on dating apps really justified?

The Rise of STIs- Are Dating apps really to blame?

In 2018, the CDC released alarming updates on the rise of STIs in the United States. An estimated 2.3 million new cases were reported that year. Over a 4-year period between 2013 – 2017, the rates of syphilis have doubled, gonorrhea is up 67% and Chlamydia infections are at record breaking highs. Similar increases in cases have also been noted in Canada and many other countries around the world. This has prompted many to wonder what’s driving this growing public health crisis.

Figuring this out has not been easy, as is often the case with studying human sexual behavior. For example, in a food borne outbreak of infection, investigations usually involve benign questions and contact tracing to identify the culprit contaminated food. On the other hand, accurate and truthful reporting on sexual exposures and practices is often confounded by reticent and heavily biased self-reporting. The reason is simple, no one wants to talk about their sex life like that! This maybe is the reason why some have suggested a theory that shifts the focus away from individuals and the judgement it implies, to the dating apps uploaded to the millions of smartphones in our pockets. Does the evidence really bear this out as true, or are we picking on an innocent bystander and ignoring more important drivers? 

Love me Tinder, Love me true

The past 15 years have seen an explosion in the popularity of dating apps with an estimated 15-20% of adults in the United States found to be active users in 2017. These apps were mostly designed to facilitate connections and potential dates between individuals with shared interests and characteristics. They work, are easy to use and have led to many long-lasting connections and relationships. It is no secret however that the ease of locating potential partners with a swipe of the touch screen, also makes these apps ideal for locating partners for casual sex. Whether this use of online dating apps translates to higher rates STI transmission may be too simplistic an explanation for a complex issue.

The Nationwide Survey of Sexual Attitudes and Lifestyles carried out in the United Kingdom is the largest study to date that has attempted to explore adult sexual behavior in the digital age and its possible association with higher rates of STI diagnosis we are seeing currently. The study surveyed 15,162 individuals between ages 16-74 over a two-year period from 2010-2012. Finding sexual partners online was reported in about 17.6% of men and 10.1 % of women and was associated with higher number of new sexual partners and more unprotected sex acts. Surprisingly this was found to be associated to with only slightly increased rates of STI diagnoses and HIV testing in men but not in women who had a same chance of getting STIs regardless of their use of online dating technology. 

For many, this may sound like an open and shut case – the multiplicity of dating apps leads to more hookups, high risk sexual behavior and ultimately higher rates of sexually transmitted infections, right?  Well not so fast, although the UK study certainly suggested that the cultural phenomenon of online dating may be contributing to some of the rise in STI infections, association does not necessarily imply causation. Also, the numbers are too small to lay all the blame on the shoulders of online dating suggesting that there are likely other factors at play and only dating apps are just the tip of the iceberg. 

Don’t blame it all on the Apps 

There is some suggestion that the higher rates of STIs are the direct result of more sensitive and sophisticated testing. We are simply finding more because we are testing more and better. This is true but we cannot ignore some of the more uncomfortable drivers that are probably contributing more to this problem than higher testing rates.

Funding cuts to effective prevention programs

In 2016 in the United States, the budget for abstinence only sex education was increased to 85 million a year. This program has been shown time and again to be highly ineffective in reducing the rates of teenage pregnancy and STIs. Furthermore, an estimated 87% of sexual health programs across High schools nationwide allow parents and guardians to opt of having their teenage children participate in this curriculum.  This had led to a generation of young adults who do not fully understand how the sexual landscape has changed and the basics of effective prevention and sexual practices.

Programs that have been actually shown to be effective such as comprehensive sexual education and contraception through organizations like planned parenthood have been indexed as drivers of “society’s moral decline” and are experiencing severe cuts to funding. Pre-exposure prophylaxis (PrEP) for HIV prevention though highly effective, continues to struggle for funding in several states. 

Ignoring the baby boomers

The focus placed heavily on millennials when it comes to sex and STIs ignores a major group – the baby boomers. Sub-group analysis of the rise in STIs shows rates which are just as alarming in those ages 60 and above. In some studies, seniors have been shown to have the lowest condom usage rates of any population.

With unwanted pregnancy no longer a concern and the advent of Viagra, baby boomers are even more liberated than ever. They often do not have the updated knowledge on navigating the risks that come with the territory of an active sex life. On the side of healthcare providers, there are intrinsic biases that make us assume that that older patients are not being sexually active, and we often do ask them about their sexual health or offer the same prevention and testing options as we do routinely for younger patients. 

Swiping happily ever after 

Ultimately digital dating technology is here to stay and a reality of the present times. The narrative of “swiping right for syphilis” is stigmatizing and unhelpful when it comes to a public health approach at curbing the rise of STIs. Do dating apps make it easier to find partners? – of course they do. Are people having more sex as a result? – they probably are. Their existence however, should not stop us from addressing the more urgent issues of better funding for effective prevention strategies and as a society, learning to speak more candidly about sex and safer sexual practices across all generations. Here’s to swiping right, and remaining cautious while casual.

Written by Boghuma K Titanji