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Scoop
6 days ago
- Health
- Scoop
Design Health Services Around People, Not The Disease
"We need to design services around people, not the disease," rightly said Dr Nittaya Phanuphak. Unless point-of-care health technologies are deployed for those who are most-in-need in a person-centred and rights-based manner, we would fail to deliver on the promises enshrined in #HealthForAll and SDGs goals and targets. "Point-of-care health technologies sitting in centralised laboratories are as good as centralised, lab-dependent ones - both remain inaccessible to those in acute need," said Shobha Shukla. "But when point-of-care tools are taken and deployed as close as possible to the communities to serve them with equity and human dignity, real change happens." Shobha and Dr Nittaya were speaking at the 2nd Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases (POC 2025) and in lead up to the 13th International AIDS Society Conference on HIV Science (IAS 2025). Dr Nittaya Phanuphak is the Convener of POC 2025; Executive Director of Institute of HIV Research and Innovation (IHRI) and Governing Council member of International AIDS Society (IAS). Shobha leads CNS (Citizen News Service) and Chairs Global Antimicrobial Resistance Media Alliance (GAMA). Community-led models proved same day "test and treat" for HCV is feasible and effective In India's Manipur, Community Network for Empowerment (CoNE) and partners did a path-breaking study to prove that same day "test and treat" is possible, feasible and effective for hepatitis C virus (HCV). They could do so because for the confirmatory test, the sample did not have to go for centralised laboratories but could be tested on WHO recommended point-of-care, decentralised, battery-operated (with solar power recharging capabilities) and laboratory independent multi-disease molecular testing platform, Truenat. So, when confirmatory test Truenat could be deployed closer to the communities, it became possible to screen people, and offer molecular test on Truenat to those who needed a confirmatory test on-spot. Result came back within an hour after which treatment initiation could be followed upon. Giten Khwairakpam, one of the study co-authors who works with amfAR's TREATAsia programme, was speaking at POC 2025. Truenat is made in India by Molbio Diagnostics, is the largest used molecular test for TB in India (and also deployed in over 85 countries globally), and over 9000 machines are deployed by the government (for TB) across India. This study enrolled 643 people (during November 2021 to August 2022) out of which 503 were screened - all were males and had a history of injection drug use. Community people who formerly had a history of injection drug use conducted the screening. 155 people were found to have viraemia, out of which 98% (153) were initiated on treatment on the same day (remaining 2 people also were initiated on treatment soon after). All (100%) completed the treatment. All (100%) those who tested negative were offered vaccination for hepatitis B virus. It is a powerful example from the communities which should inform national and global policies for improving hepatitis responses on the ground - in person-centred manner. Philippines' Bantayan offers another strong example when point-of-care tools are deployed at point-of-need In multiple islets of Bantayan in the northernmost part of Cebu, Philippines, only around one-third of the estimated TB cases could be notified before the pandemic. But after the introduction of new TB screening and diagnostic tools, now almost all the TB (99%) is found in 2024. Dr Samantha Tinsay, government Municipal Health Officer, Bantayan, Cebu, Philippines and her team made a major difference in bridging the gap between TB services and people who were left behind on islets of Bantayan. She took point-of-care and battery operated AI-CAD enabled X-Rays and Truenat (point-of-care, battery-operated, laboratory independent and de-centralised molecular test) - both kept safely in a moulded plastic box - loaded on a pump boat - and went from islet to islet - screening people for TB and offering confirmatory Truenat molecular test on the spot. Within an hour or so, those found with active TB disease were linked to TB treatment care pathway. New TB case notifications, as well as treatment success rate, increased manifold. But the journey was not easy - also due to inclement weather and stormy seas. Dr Samantha's untiring efforts have resulted in a tremendous increase in TB case finding: the number of persons screened for presumptive TB went up from 187 (in 2019) to 2506 (in 2022), 2027 (in 2023), and 5679 people in 2024. 'TB treatment success rate has also increased to 97% in 2023,' she confirmed. Average TB treatment success rate in the Philippines was 78% in 2023 as per the WHO Global TB Report 2024. Imagine the difference it can make in the Philippines' response to end TB if such interventions can be scaled up and become a norm. Dr Darivianca Elliotte Laloo, who has earlier served at the Stop TB Partnership and International Union Against Tuberculosis and Lung Disease (The Union) and currently leads Molbio Diagnostics as General Manager, chaired this session at POC 2025. She said that Truenat, which was validated independently by the Indian Council of Medical Research of the Government of India in 2017, offers PCR molecular testing for over 40 diseases (including current strains of COVID-19). Being WHO recommended battery-operated, laboratory independent, decentralised and point-of-care molecular test for TB with solar power charging capacities, it is increasingly getting deployed in peripheral areas of several high-burden countries now. Largest rollout of Truenat in Africa took place in Nigeria last December. Nigeria is home to largest number of people with TB in Africa. We need to close the gap between people-in-need and point-of-care standard diagnostics by taking services closer to them or at their doorstep, said Dr Laloo. Colossal cost of misdiagnosis on communities Noted #endTB activist Blessina Kumar who leads Global Coalition of TB Advocates (GCTA) shared a powerful real-life testimony of Meera, who survived one of the most serious forms of drug-resistant TB (Extensively Drug-Resistant TB or XDR-TB). If someone had XDR-TB in 2012, there were tools back then too, to test for TB and drug-resistant TB within 100 minutes. And after drug-susceptibility testing (to ensure that TB bacteria is sensitive to medicines used in the therapy), an effective treatment could have helped Meera towards cure. But misdiagnosis caused havoc: She had to endure the rigours of going through TB treatment for six years (2012-2018). She also had to spend around INR 300,000 (~USD 4000) as well which is a grim reminder that delayed or wrong diagnosis often results for catastrophic costs for people in need. She also had to be stay away from her 4 months old son because of TB. TB stigma and discrimination also did not spare her: she was not allowed in the kitchen or living room, and had to use separate utensils and clothes. She not only battled depression but also attempted suicide twice. Experts say that soon after initiation of an effective TB treatment, a person becomes non-infectious. But TB stigma and discrimination still lurks. After 6 years, Meera finally got the right diagnosis and treatment, and could get cured. She advocates for person-centred TB care since then. In 2025, if anyone has XDR-TB or any other form of drug-resistant TB, it should take an hour or two for confirmatory TB test (upfront molecular test) and treatment hopefully will be over in next six-months using the latest WHO recommended regimen - and with full health and social care and support. Imagine the difference it can make if we deploy science-based standard healthcare tools to serve the people where they are in person-centred manner. Inequities and injustices firewall most-in-need people from accessing standard care "It is not lack of TB diagnostic, treatment and prevention tools that are causing human suffering and killing people but inequity and injustices that plague our world. For example, rich nations like Australia could bring down TB rates to elimination level 50 years ago with whatever tools they had. In USA, lab on wheels with X-Rays were going to remote areas to find more TB in 1950s," said Shobha Shukla. "I have myself seen TB pins of 1940s and 1950s that were worn by people in USA to declare that they had taken an X-Ray to screen for TB." But, in the Global South, even after 50-70 years - it is not so common as it should be - to see lab on wheels taking an (AI-CAD enabled) X-Ray and molecular test closer to the unreached people with standard TB services. WHO called upon all governments in 2018 to replace microscopy with 100% upfront molecular testing for TB by 2027. All world leaders agreed to do so too in their Political Declaration of United Nations General Assembly High-Level Meeting on TB 2023. Despite this, out of those who got diagnosed, more than half (52%) did not get upfront molecular test in 2023 – rather they got microscopy or were not bacteriologically confirmed at all. Most of them would be in the Global South, wonders Shobha. "Early and accurate diagnostics is the ONLY entry-gate towards TB treatment care pathway. It reduces catastrophic costs faced by the most vulnerable, reduces avoidable human suffering and risk of TB death and helps stop the spread of TB infection," she said. 100 days campaign in India heralds a foundational shift on how we find TB based on science and evidence India's TB Prevalence Survey 2019-2021 showed that almost half of TB patients were asymptomatic. The Indian govt-led 100 days campaign from 7 December 2024 to 24 March 2025 was launched in 347 most affected districts to screen everyone regardless of symptoms among high-risk populations, including homeless and migrants. After 24 March 2025, given the impact, it was expanded to all 806 districts nationwide. As per government's concept note of 100 days campaign, vans were to go closer to high-risk groups with Artificial Intelligence Computer-Aided Detection (AI-CAD) enabled portable X-rays, Truenat molecular test machines for sputum testing, and other tests as required. 129.7 million people were screened and over 285,000 asymptomatic people with active TB disease were found – all of whom would have been missed if AI-CAD enabled X-ray was not done. "Imagine the public health impact of stopping TB spread, reducing human suffering and putting an additional nearly 300,000 to path of healing perhaps," said Shobha. Walk-the-talk on multi-disease elimination approach "As WHO multi-disease elimination approach is being finalised, we need to recognise that we have a lot of under-utilised multi-disease tools which we use for TB only. Truenat offers molecular testing for over 40 diseases. Likewise, artificial intelligence we use for TB detection, such as DeepTek's Genki and QureAI, both screen people within seconds for a number of diseases (DeepTek's Genki screens for more: 26 pathologies)," said Shobha. "Let us be responsible and fully optimally utilise diagnostic infra we have at point-of-need and scale them up too. It helps with pandemic prevention, preparedness and response too." And with regards to TB, follow the science – screen everyone in high-risk settings in people-centred manner. Bobby Ramakant – CNS (Citizen News Service) (Bobby Ramakant is part of CNS (Citizen News Service) and a World Health Organization (WHO) Director General's WNTD Award 2008. He is also on the Board of Global AMR Media Alliance (GAMA) and Asia Pacific Media Alliance for Health and Development (APCAT Media). Follow him on X: @bobbyramakant)
Scoop
17-06-2025
- Health
- Scoop
To Be Or Not To Be? Daily Oral Versus Long-Acting Injectable Medicines For HIV Prevention
Scientific research has gifted us with a range of evidence-based options to protect ourselves from getting infected with HIV. In 2012, US FDA had first approved Pre-Exposure Prophylaxis (PrEP) daily oral medicines for HIV prevention. More recently, long-acting injectable options of PrEP are also approved. We at CNS listened to the experts on both of these PrEP options so that we can make an informed choice. A lively debate was organised at the recently concluded 10th Asia Pacific AIDS and Co-Infections Conference (APACC 2025) in Tokyo, Japan, on "Should Long-Acting Injectables (LAIs) Replace Oral Antiretrovirals for Biomedical HIV Prevention in the Asia-Pacific Region?" Also, 13th International AIDS Society Conference on HIV Science (IAS 2025) and 2nd Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases (POC25) will open soon. Arguments in favour of long-acting injectable PrEP dwelt upon the current dismally low use of oral PrEP in the Asia Pacific Region - as of end 2023, around 204,000 individuals were actively using PrEP - just 2% of the 8.2 million target set for 2025. Also a significant number of individuals discontinue PrEP within a relatively short period of time after initiation. For example, in Thailand, a programme serving over half of all PrEP users, saw 47% of clients discontinuing within 12 months, according to the Institute of HIV Research and Innovation (IHRI). "I don't fear the side effects. I fear the side eyes" Varied reasons were put forward by debater Jennifer Ho, a global health advocate from Thailand, included "Oral PrEP is not reaching those most at risk. Transgender women navigating stigma in clinics, sex workers who cannot safely carry pills; men who have sex with men and young men hiding their PrEP from family; persons who use drugs facing criminalisation - all of these find it difficult to take daily oral PrEP. Pill shaming keeps people from starting or leads them to quietly stop, because of 'I don't fear the side effects. I fear the side eyes.' On the other hand, long-acting injectables remove structural and behavioural barriers and can reach people outside formal systems. We need prevention tools that meet people's needs. Prevention works when it does not depend upon disclosure, disability or perfect routine. Oral PrEP stigmatises life because you have to take a pill daily. Long-acting injectables are discreet, there is no daily pill to remember, there is no need to hide. Long-acting injectables are a prevention strategy that is realistic, respectful and responsive." Dr Nagalingeswaran Kumarasamy, a well known infectious disease expert from India gave a doctor's perspective on the necessity of long-acting injectable PrEP. He serves as Chief and Director of Infectious Diseases Medical Centre at Voluntary Health Services Hospital in Chennai, India. He is also the Secretary General of AIDS Society of India (ASI) - a nationwide network of medical experts and researchers on HIV, co-infections and co-morbidities. Dr Kumarasamy said that daily PrEP pill is not a suitable or desirable prevention strategy for everyone. We need more options as well as expanded access or use by key populations (people who are at a heightened risk of HIV). Long-acting PrEP will likely be a very cost-effective improvement over standard PrEP but may require novel financing mechanisms that bring short-term fiscal planning efforts into closer alignment with longer-term societal objectives. Cost effectiveness is different from cost of sale. Long-acting injectables will be cost effective in the long run. It is too much to expect daily adherence from people who are not sick. Also studies have found that long-acting injectables like cabotagravir and lenacapavir to be superior to oral PrEP. It is not about 'either/or' but expanding options for HIV prevention While conceding that long-acting injectable PrEP is promising, Danvic Rosadiño, Co-Chair, WHO Guidelines Development Group on Long-acting Injectable Cabotegravir for HIV Prevention, firmly argued that replacing oral PrEP is premature, impractical and inequitable. Danvic heads programmes and innovations at LoveYourself in the Philippines. "It is not a question of 'either', 'or'. It is about expanding options, and not eliminating them. In a socially, economically and politically diverse region like the Asia Pacific, this will risk undermining progress. The three core reasons why oral PrEP should not be replaced is cost, convenience and confidence," he said. "Long-acting injectable PrEP is far more expensive than generic oral PrEP. How many governments of this region will be able to afford long-acting injectables? If we replace oral PrEP, we will be leaving the most vulnerable behind. We have been able to roll out PrEP in a very de-medicalised manner. We have built our systems which allow oral PrEP to be accessed in community clinics, in mobile clinics, in peer outreach facilities. It is easy, discreet and empowering, especially for those avoiding judgmental or stigmatising healthcare settings. However long-acting injectables might bring us to clinical dependence, and many of our clients do not feel welcome in clinical facilities. We set up communities for giving oral PrEP because the mainstream system was not built for us. It excluded and stigmatised the community. We have created alternate spaces where people could feel safe, respected and seen not just as patients but as people. If we shift HIV prevention back to clinical systems, we risk destroying those safe spaces. Long-acting injectables might require clients to go back to those places which they actively avoided. Granted that long-acting injectables are very promising, replacing oral PrEP with them would create barriers and not bridges. We must protect choice. Different people need different things-some will prefer pills, some will prefer injectables. Let us invest in building a system where these options co-exist and where everyone- no matter where they live - can access HIV prevention that works for them," said Danvic. Do not forget stigma, inequity and costs Dr Rayner Kay Jin Tan, an Assistant Professor at the Saw Swee Hock School of Public Health, National University of Singapore, supported Danvic. He opined that 'Stigma, inequity and costs are very important considerations when we think about PrEP and other HIV prevention products. Keeping these things in mind, we should not replace oral PrEP with long-acting injectables. Oral PrEP has been de-medicalised to a large extent and distribution is community driven, thus bringing access to communities. And the cost of long-acting injectables is still not known. No generic manufacturer has given any idea of what it would cost. And most of the HIV infections are in countries that will not be able to meet the high cost of long-acting injectables. Except for Australia, no other countries in the Asia-Pacific have approved any long-acting injectable PrEP. However, both sides agreed that not everyone needs the same prevention options, but everyone deserves what works best for them. Speed, scale, implementation, and equity must be at the core of translating exciting scientific tools into public health impact. Give real choices to people to choose from full range of HIV combination prevention options It is now for the readers to decide which premise do they support- long-acting injectables or daily oral PrEP -till science develops more exciting HIV prevention tools. And above all, expanding the range of prevention options to protect ourselves from HIV should always remain the mainstay - and trusting people to have real choices if all combination prevention options are offered to them. Oral PrEP or pre-exposure prophylaxis is an HIV medicine taken daily by HIV negative individuals that reduces their risk of acquiring HIV through sex by about 99% and from injection drug use by at least 74%. PrEP should be used with condoms when possible. There are newer approved PrEP options that also protect us against few STIs, like Doxy PrEP (which provides reasonable protection against getting infected with STIs like syphilis, chlamydia, and gonorrhoea). Know more about long-acting injectable PrEP Since 2022, one of the long-acting injectable PrEP has a medicine called cabotegravir which has shown high efficacy in protecting us from HIV. It involves injections administered intramuscularly, with the first two injections given four weeks apart, followed thereafter by an injection every 8 weeks. Studies have shown it to be safe and superior to daily oral PrEP (which uses medicines like tenofovir and emtricitabine) for HIV prevention among cisgender women, cisgender men who have sex with men, and transgender women who have sex with men. It offers a promising alternative to daily oral PrEP, particularly for individuals who may face challenges with adherence to daily medication. It was recommended by the WHO in 2022 as an additional HIV prevention option for people at substantial risk of HIV infection. However, its current high cost of US$ 22,000 per year per user jeopardises its potential for public health benefits. In July 2022, its manufacturer ViiV Healthcare announced a voluntary license with the Medicines Patent Pool, allowing 90 countries to buy generic versions of cabotegravir for HIV prevention. The cost of generic version is expected to be potentially around US$ 16-34 per person per year. However, generic versions will not be out before 2027. Long-acting Lenacapavir Long-acting lenacapavir PrEP given as a subcutaneous injection once every 6 months, has been found to be highly effective. In 2024, two landmark clinical studies- PURPOSE 1 and PURPOSE 2- showed it to be 100% efficacious in preventing HIV among cisgender women and 96% efficacious among men who have sex with men, transgender and gender non-binary individuals, and was found superior to oral PrEP. It is currently priced at US$ 42,250 per year per person in the US, but is expected to become much more affordable to around US$ 200-300 per year per person with the introduction of generic versions, that are expected to be available by 2027. Shobha Shukla – CNS (Citizen News Service) (Shobha Shukla is the award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate. She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media) and Chairperson of Global AMR Media Alliance (GAMA received AMR One Health Emerging Leaders and Outstanding Talents Award 2024). She also coordinates SHE & Rights initiative (Sexual health with equity & rights).
