In the Absence of Promiscuity, PrEP is Useless

An IRIN article ends with a comment from Dr Helen Rees: "I'd ask why we're doing these studies in these countries at all if we're not going to implement any of these interventions,...I find that unethical." What I find unethical is that these interventions all assume that HIV is primarily transmitted sexually, despite evidence to the contrary.

However, these drug trials have shown one very significant thing: most African people don't have sex a great deal. Their sexual behavior is not extraordinary. And Modes of Transmission Surveys for Kenya and Uganda show that it is ordinary people in long term monogamous relationships that contribute the vast majority of HIV infections in those countries. And yet HIV transmission rates are extraordinarily high.

If you had unlimited amounts of money, you could unleash PrEP on whole populations. It would be a stupid and dangerous thing to do, but if you think, as the HIV mainstream do, that most Africans have enormous amounts of high risk sex all the time, you might think it would be worthwhile.

But there isn't even enough money to supply half of the people globally in need of antrietroviral (ARV) drugs with treatment. The majority of people globally have never been tested for HIV. The majority of HIV positive people globally don't know their status. And PrEP would require that everyone, or most people, be tested as much as four times a year.

PrEP advocates need to get things in perspective. We know a lot less about HIV transmission than we should, given the amount of study that has been done over the years. We are not in a position to consider HIV prevention programs that involve vastly higher numbers of people (and finance) than current programs, which are struggling, despite claims to the contrary.

It's a sobering thought that HIV transmission rates are still very high in countries with very large ARV programs. Also, death rates are very high among people on treatment. People are dying, not because they are HIV positive or because they have AIDS, but because they have preventable and treatable conditions that are just not being treated.

Developing countries with high HIV prevalence have low levels of education, health, infrastructure and many other factors that are intimately related to rapid HIV transmission. Churning out drugs in ever increasing quantities is not going to change things much, especially if evidence that HIV is not primarily sexually transmitted continues to be ignored.

What we are ethically obliged to do is to be frank and honest about sexual transmission of HIV: we don't know why transmission rates are hundreds of times higher in some parts of some African countries than they are in most countries, developed and undeveloped. Therefore, we cannot continue to base most prevention programs on the assumption that Africans have superhuman amounts of sex.

PrEP may turn out to have some use but we have, as yet, no idea what that would be.

[For more on the false hypothesis about African promiscuity, see my other blog.]