Can we treat our way out of the HIV epidemic? Yesterday I wrote a piece in The Guardian suggesting that the “Test and Treat” approach was a triumph of optinism over common sense. Today, I am a homophobe, a media slut, a cherry-picker of data and over 120 other things, mostly nasty.
My favourite, gloriously rude comment came from The Bathhouse. It summarised my “inflammatory and simplistic” argument thus:
1.) The AIDS mafia want treatment to replace prevention in Africa because they think that people on ARVs are less infectious, therefore reducing the spread of HIV.
2.) What the fools don’t realise is that people are most infectious soon after having contracted HIV so the screening is unlikely to help identify people in time
3.) Availability of treatment makes people less worried about HIV and so indulge in more risky behaviours
4.) Treatment is bad and people who think it is a good idea are optimistic simpletons
I’m prepared to accept, more or less, that the first three contentions are inflamatory and simplistic summaries of the argument I made. But how you get from that to “treatment is bad” is beyond me. How observing that new HIV infections have been rising among gay men since treatment became widely available makes me homophobic is a bit of a mystery to me too. We’ll have to stick that label on researchers in an awful lot of countries: data from Australia, Canada, England, Germany, the Netherlands, New Zealand, Spain, Scotland, Switzerland and the United States support the claim. A good recent review can be found here. For those that don’t want to bother reading a whole paper, here’s a picture to look at, from Scotland.
The graph shows newly-identified infections. That’s not a true measure of new infections, because it depends on who gets tested. And obviously there was more of an incentive to get tested after treatment became available. But why would that affect gay men selectively, rather than drug injectors and heterosexuals? The fact is that drug injectors don’t want to share needles whether or not they face the threat of HIV. So becoming less worried about HIV does not lead to an increase in needle sharing. Gay men, on the other hand, just like straight men and women, would often really prefer to have sex without a condom. The threat of AIDS is a pretty big disincentive to unprotected sex. The threat of HIV is a lesser disincentive. The uptick among heterosexuals has been less pronounced than among gay men simply because in Scotland, prevalence is far lower among heterosexuals. So any drop in condom use in sex between men and women will result in relatively fewer new infections.
Does that make me homophobic? Not unless someone’s been giving out the black-and-white glasses. In the same way as saying that more treatment means more people living longer with HIV does not make me anti-treatment. No-one who has seen friends die because they live in a place where they couldn’t get treatment could possibly be anti-treatment. We should be expanding treatment for its own sake. We also know that treatment reduces viral load among those who take it regularly, and who don’t have other STIs (athough any amount of viral load in someone who is kept alive through treatment is, whether you like it or not, higher than the viral load of someone who has died because they didn’t get treatment.) Treatment is GOOD, in its own right. We don’t need to build computer models based on entirely unrealistic assumptions in order to justify the need for more treatment. We DO, however, need to face the fact that until now, more treatment has been associated with more new infections. The world does not exist in black and white, in treatment OR prevention. The fact is, as we expand treatment, we need to expand other forms of effective prevention, too.
Can the wicked witch go back to her coven, now?