Science Awards: Virtuous Circle or Spooky Cabal?

There are few things that make me think 'collusion of interested parties' than prominent awards, with the exception of peer reviewers, who always me think of Freemasons for some reason. For all I know, though, they could all be completely innocent and/or unrelated.

Anyhow, Science Magazine has awarded two of their ten prizes to the highly controversial and unconvincing Tenofovir vaginal gel (the CAPRISA 004 trial) and the almost equally unconvincing pre-exposure prophylaxis drug (the iPrEx trial). There is a lot of USAID and PEPFAR funding behind both of these, so the poor trial results may not matter too much.

The ongoing concentration on capital hungry technologies and technical expertise tends to mask one of the biggest problems that poor countries face: shortage of skilled health personnel. Here in Tanzania there is one doctor for approximately every 50,000 people (compared to about one for every 170 people in Cuba). What are people going to do with all these drugs and other technologies, assuming they can ever afford them?

This problem, like many of the other real problems developing countries face, is ignored by the cabals of industrialists, megaphilanthropists, technologists, politicians, religious fanatics and other jackals of the HIV industry. But it is not going to just go away.

Of course, it's of little interest to the same interested parties, who wish to establish markets, not undercut the very source of their current and future wealth. In addition, HIV related technologies need to be put through rigorous trials in countries with high HIV prevalence to prove their worth. So even if 'aid' money will not be diverted to subsidize these markets, contacts with developing countries need to be maintained. After all, that's what 'aid' is, a tool of foreign policy.

Botswana has announced that it is going to concentrate on prevention, and not before time. The country has one of the worst epidemics in the world. But perhaps now they will reject the self-serving arguments about treatment 'being' prevention and about HIV funding 'strengthening health systems' or about it  not diverting funding from other health issues. If only other high prevalence countries, and even low and medium prevalence countries, would follow suit and stand up to the moneyed interests.

Botswana simply can't afford antiretroviral drugs at current levels of usage, never mind the annual increases in incidence adding to the costs, along with resistance and other factors ensuring that costs will rise exponentially, not linearly, in the future. All high prevalence countries with large numbers of people on antiretroviral drugs are experiencing the same problems as Botswana.

But Botswana also seems to have realized that much of the money spent on behavioral interventions has been wasted. Perhaps they'll take another step and realize that this failure of behavioral interventions may be because HIV transmission is not all about sexual transmission?

Using mere technologies to solve deeply rooted development problems is as likely to work as planting seeds on the moon (in its present state). And if I thought the HIV industry really wanted to solve development problems, health and HIV related problems in particular, I would think they are behaving like fools.

But I don't think anyone seriously believes such naive claptrap. They are business people, involved in protecting their markets and ensuring that they make as much money as possible, regardless of the consequences for people in developing countries.

Treatment as Prevention: Treating People to Death

There was an attack on 'treatment as prevention' in March which came from a person you wouldn't expect to oppose a technological quick fix, Elizabeth Pisani. Despite the fact that she disagrees with UNAIDS in some ways, she is an adherent of the behavioral paradigm. It seems a pity to hold views that challenge the mainstream and yet still cling to the mainstream's central premise about HIV: that it is almost always transmitted through heterosexual sex in African countries.

But it's worth citing her opposition to a strategy which has a lot in common with PrEP. Firstly, Pisani points out that "HIV is most infectious in the few months after a person is first infected. Even if everyone got tested annually, we’d miss most of these new infections." I hope the 'modelling' work that is said to support treatment as prevention includes this point, but I doubt it.

Pisani also notes that there are a number of circumstances under which viral load (infectiousness) can spike, such as contracting another sexually transmitted infection (or perhaps other diseases) or failure to take medication correctly, which can occur for many reasons. Such a spike would increase infectiousness in people who may well be engaging in unprotected sex.

Pisani refers to findings relating to treatment becoming more widely available in rich countries. Apparently rates of unprotected sex increases as a result of 'disinhibition', engaging in unprotected sex in the belief that the risk is now low. Many have claimed that disinhibition does not happen to any great extent in African countries. The 'model' used by proponents of treatment as prevention believe that disinhibition will not significantly contribute to HIV transmission and that adherence to drug regimes will be extremely high in African countries.

Pisani casts doubt on both of these claims. I have to say, I agree. I would suggest that the finding that disinhibition is low in African countries is more likely to indicate that HIV is not as closely related to sexual behavior as we have been led to believe.

As for claims about high levels of adherence, I'm not sure if figures for treatment in countries like Kenya and Tanzania are very complete or credible. Death rates among HIV positive people seem to be high enough to keep prevalence steady and there is no evidence that sexual behavior has been influenced greatly by behavior change programs.

I'd say UNAIDS, and Pisani herself, are over-optimistic about a lot of things. Treatment as prevention sounds, on the surface, like a good idea. But it's not going to be enough on its own, especially if only sexually transmitted HIV is being targeted. Waiting till people become infected and then treating them, hoping that they will all become less infectious and therefore slowing down the epidemic, is ludicrous.

Even if HIV is 100% sexually transmitted this would not work. We must know by now how hard it is to influence people's sexual behavior or, indeed, any other kind of behavior. But HIV is also transmitted non-sexually. It is vital to establish the contribution of non-sexual HIV transmission to serious HIV epidemics, otherwise sexual transmission will continue to be overestimated. As long as we overestimate sexual transmission, HIV will continue to spread.