Adherence has become the bogey man of living with HIV infection.
Reams of paper on this subject uncovered little new. Indeed the only
point worthy of highlight from these sessions was that one key predictor
of non-adherence is gender. Women have greater problems with adherence
due to the demands of daily life: family and child rearing
responsibilities, as well as concerns about disclosure and lack of
gender-appropriate information complicate their abilities to integrate
such complex regimens with their daily tasks. Adherence guru Dr Margaret
Chesney called for researchers to pay attention to good adherers (of
any gender) and to attempt to identify successful strategies that could
A joint investigation by the Community Research Initiative of
Toronto and Ottawa Hospital revealed that adherence levels of 91% or
greater were associated with the best chance of maintaining viral
suppression below 50 copies/ml. Keeping viral load below 50 copies is
associated with the best long-term chances of preventing viral load
rebound and drug resistance, and the most durable long-term response to
In comparison, individuals who achieved viral load below 500
copies/ml but above 50 copies/ml had an average adherence rate of 79%.
These findings suggest that interventions which result in marginal
improvements in adherence may still have an important long-term impact.
Should treatment optimism lead to prevention pessimism?
For Australian workers, familiar with Professor Gary Dowsett’s
"post-AIDS" analysis there was little new data presented at the Ottawa
AIDS Impact conference, where some US researchers appeared to be
discovering that things had moved beyond a crisis mentality. Eric Rofes
made spirited comments about US gay men feeling torn between a
Crisis-Cure polarity, and argued that the "AIDS industry" was heavily
invested in trying to recreate the former, while the bulk of gay men
were choosing to live life at the other end of the spectrum. Professor
Graham Hart of Glasgow University speculated on the need to avoid
overuse of the post-AIDS concept, arguing that some places are currently
pre-AIDS and others mid-AIDS. Certainly for such a cultural analysis to
be valid, local specificity is crucial, and timing and scale of the
epidemic is everything.
The few papers that attempted to unpack
the real significance of post-AIDS in places with well established
epidemics were, unsurprisingly, the most interesting. There was
encouraging unanimity - if disturbing results - from researchers in San
Francisco, London and Sydney about the impacts of HIV treatments
awareness on the sexual practice of HIV-uninfected gay men.
Doctors Maria Ekstrand from San Francisco, Dr Lorraine Sherr from
London and Professor Sue Kippax of Sydney all reported that
HIV-negative gay men who expressed the most optimism about new
treatments were also the most likely to have unprotected anal
intercourse with a partner of different or unknown HIV status. None of
the three were willing to speculate on whether the optimism was a
trigger, or a post-hoc self-justification for risk taking. More research
is necessary - and Kippax proposed some standard inter-country
questions to enable systematic gathering of data, and presented a
validated set of attitude statements, such as "An HIV+ person on
combination therapy is unlikely to transmit HIV" and "I’m less worried
about HIV than I used to be".
Kippax reported that the only statement significantly associated
with unprotected anal intercourse amongst HIV-positive men in Sydney was
"undetectable viral load cannot pass on the virus". This finding was
not replicated in the London survey, conducted in May 1998 amongst 1018
Maria Ekstrand argued vigorously for those involved in HIV
treatment education to be aware of the impact of their work on the
general population of gay men. Integrating education for PLWHA with HIV
prevention work is standard for Australians who have always accepted the
centrality of PLWHA in such a way. Yet it was chilling to hear about
the complexities of such an approach in San Francisco where
pharmaceutical companies buy bus shelter ad sites to promote images of
mountaineering as the latest side effect of HIV infection. Bombarded by
such health-enhancing images it may be difficult for uninfected men to
perceive HIV as something that particularly needs to be avoided.