Will Profits From the HIV Pandemic Ever Be Accompanied By Progress?

The answer to the question 'will Africans most in need of PrEP be able to access it?' is not a straightforward yes or no. If the question were 'will Africans in need of the most common and effective drugs for the most common, treatable, preventable and deadly diseases have access to them?', the answer is 'they certainly don't have access right now'. So why should we believe they will ever have access to PrEP?

But the question is harder to answer than that. Even if the HIV industry were to wave a magic wand and grant PrEP to whoever needed it most, they have no idea who those people would be. They don't know who is at most risk of HIV infection or of transmitting HIV and they have never known. Or they have never been quite frank about it.

There are Modes of Transmission Surveys, but these are figures cobbled together from a disparate collection of assumption, guesswork, prejudice, overactive imagination and devotion to the tooth fairy. In the end, some Africans are more likely to be infected than others, but those the industry says are most likely to be infected are not the most likely, or they are not likely to be infected for the reasons the industry says.

The majority of infections in East African countries are in married couples and those in long term relationships. Many of these people are not promiscuous, many only have sex with their partner, they don't have sex very often and many of them even take precautions to prevent infection with HIV, other sexually transmitted infections and unplanned pregnancies. In other words, a disease that is difficult to transmit through any kind penile/vaginal sex is commonly transmitted through low-risk heterosexual sex.

An update from a recent conference doesn't mention the above issues. It is accepted that effectiveness is only moderate. But there is a tendency to believe that adherence will, almost miraculously, become better than anything every seen in the history of healthcare that focuses on technical fixes.

One only need look at the number of HIV positive people who die without treatment, the number who die on treatment, the number whose treatment has failed and they are seriously ill, the levels of resistance that are mounting up over the years, etc, to wonder where all the optimism about PrEP comes from. It may be great, but will it have a great impact, or any impact, where it is most needed?