Two of the Republican senators accused of holding to ransom some US$ 50 billion in US funding for HIV in Africa are fighting back. They are also ill-educated, badly confused, or lying through their teeth.
After a Washington Post editorial accused them of foot-dragging on AIDS funding in part because they worried that money might be used for sensible things like clean needles and condoms, Richard Burr and Tom Coburn had this to say:
When it comes to AIDS, treatment is prevention. If we fail to aggressively treat patients, we endorse the spread of the virus. By requiring that the majority of PEPFAR funds go toward treatment, we are working to prevent the spread of this devastating virus.
Let’s take that apart. “When it comes to AIDS, treatment is prevention.” So far so good. Treating HIV infection reduces the amount of virus in circulation, allows the body to restore the immune system and reduces the likelihood that other diseases, clustered under the name AIDS, get the upper hand. So treatment clearly prevents AIDS. But does it prevent HIV? Aaaah, now that’s a very different question.
The more HIV you have in your body fluids, the easier it is to infect someone else in unprotected sex or by sharing needles. So many of us have fantasised that lowering viral loads through treatment would significantly reduce HIV transmission. At the individual level, it is true. But across a population, it doesn’t seem to work like that. Countries that have near-perfect access to treatment for everyone who has been diagnosed have NOT seen new infections drop in the groups most at risk, and some are seeing them rise, especially among gay men. What seems to be happening is this: treatment is indeed preventing AIDS (and thus death). So people are less scared of getting HIV. On top of that, they assume that it doesn’t matter too much if they have unprotected sex with someone infected, because everyone who’s infected is on treatment, so they have low viral loads and are unlikely to pass on the virus. So why the hell bother with a condom any more? Unprotected sex rises.
Here’s the problem: people are most infectious when they are newly infected. And that’s when they are least likely to have been diagnosed, and are least likely to be on treatment. If condom use falls across the board, people who are newly-infected (and highly infectious) are more likely to be passing on their infection. More treatment definitely means more people living with HIV, obviously, simply because people who are already infected aren’t dying. But the data suggest that even in a world of near-perfect access to treatment, more treatment can also mean more new infections. In a less-than-perfect treatment scenario such as that found throughout Africa, we could get a messy mix of the lower concern and rising risk that comes with the PERCEPTION of treatment availability, without the advantage of lower viral load that comes with perfect treatment. In other words, it’s even more likely that new HIV infections will rise.
So yes, treatment prevents AIDS. But it may actually INCREASE HIV. And that in turn will increase the number of people that Senators Coburn and Burr need to find money to treat. Wouldn’t it be better to invest more of the money in making sure that those people never need treatment in the first place? As more people start taking HIV drugs, we need more money for effective HIV prevention, not less.