Many people, including the head of the WHO’s HIV division Kevin de Cock, have observed that “we can’t treat our way out of this epidemic”. Today, The Lancet publishes a paper by many people, including the head of the WHO’s HIV division Kevin de Cock, claiming that we can, in fact, treat our way out of the epidemic.
The paper is based on a mathematical model which assumes that all adults get tested for HIV once a year, and all get put on treatment as soon as they test positive. This “theoretical strategy” could reduce HIV transmission to negligeable levels within 10 years of being implemented, even in an epidemic as widespread as South Africa’s.
This approach, referred to in an earlier galley version of the paper as a “proposed strategy” rather than a “theoretical strategy”, is born of despair. HIV is a (largely) sexually transmitted infection which can be prevented by cutting down on the turnover of sex partners and using condoms. But many people (I’m one of them) would rather risk infection than do what it takes to prevent it. And the reluctance to adopt safer behaviour is particularly pronounced among some of the people who need it most — heterosexuals in Africa and gay men worldwide. The advent of treatment and the disappearance of AIDS appears to be eroding even further the already feeble motivation to cross our legs or use condoms in non-commercial sex. Vaccine research is in a slump, and microbicides continue to disappoint. So what the hell, let’s argue for universal (voluntary — another insistent addition to the paper at the galley stage) testing and treatment.
The problem is that getting all adults to take an annual HIV test and supplying over 30 million people with expensive drugs that have to be taken with daily diligence to reduce the very real threat of resistance is at least as far fetched as persuading people to use condoms. Lesotho’s Know Your Status campaign, which aimed to provide testing and access to treatment for 1.3 million people, racked up just 25,000 tests close to the time it was scheduled to be finished, according to a report from Human Rights Watch. Even in the countries that have very strong health systems where testing is actively promoted among those most at risk we are failing to get people tested and treated. The new data published yesterday by Britain’s Health Protection Agency show that despite a push for more testing, exceptionally high levels of knowledge and awareness and universal access to free treatment, over 3000 gay men were newly diagnosed with HIV in the UK in 2007. One in five weren’t diagnosed until after they effectively had AIDS.
Are current prevention efforts doomed to failure? Perhaps. But that is no reason to replace them with a treatment approach which is just as likely to be doomed to failure. Interestingly two of the paper’s authors also contribute to The Lancet a commentary that questions the feasibility of the “theoretical strategy” that promises such good results. Instead of running mathematical models, perhaps the (rightly) concerned folks at WHO could persuade a single rich, well-governed country with a strong health system and minimal issues of stigma to show their “theoretical strategy” can work in practice. After all, mathematical models show that the theoretical strategies of abstinence, mutual monogamy among the uninfected and universal condom use are 100% effective in wiping out HIV. Though we’ve been pushing those for years, we’ll still have 2.5 million new infections this year.