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.

Now we know. “The £15 pill to protect against HIV” was the headline in Metro, the Daily Mail’s give-away version. More muted than I would expect, but Metro is really the Mail Lite. The article, bylined Jo Steele, does indeed seem to have been stolen wholesale from a much more rigorous piece in the New Scientist, headlined Safer Sex in a Pill.

Missing from the headline is a question mark. While the New Scientist piece does point out that we’re not sure that PrEP works, the Metro piece glosses over the uncertainty, saying (wrongly) that Viread and Truvada “have proven successful in human trials involving 19,000 gay men”. Anthony Fauci is quoted as saying “There’s a lot of buzz about PrEP. There’s some cautious optimism this will work”. I see a lot of optimism, not much of it cautious. My favourite example of the glass being half full comes from Bob Grant, from UCSF. He doesn’t think that people who take a pill so that they can have more unprotected sex will actually have more unprotected sex.

“Bob Grant, who researches HIV prevention at the University of California, San Francisco, and helped run the African trial, speculates that some users may even have less unsafe sex. “PrEP might put people in a different frame of mind,” he says. “When people take a pill a day, that reminds them that they are at risk of catching HIV.”

Hmmm. I took pills every day for about two decades so that I could have unprotected sex without catching pregnancy, and I never once thought: ah yes, I took a pill this morning to help avoid pregnancy, and sex can lead to pregnancy so I’d better not have sex.

I’m all for increasing HIV prevention options, especially ones that have been proven to work (if only in some circumstances, some of the time). But I do think we also have to recognise that what works for an individual may not work so well at a population level — we’ve seen this with the roll-out of ARV among gay men in rich countries. Individually, infectivity goes down, but at the population level, new cases are rising. Look out for a paper and commentary along these lines in The Lancet next week. A number of authors from the WHO will argue that testing all adults annually and putting everyone infected on ARVs would essentially wipe out HIV transmission within 10 years. In a commentary, some other authors from the WHO conclude that it would be a good idea, but might be hard to do in practice.

The truth is that what works in a clinical trial (or even on the much thinner ice of a mathematical model) can not always be made to work in practice. There will be a lot of resistance to PrEP at first, not least from the people who already object to giving out condoms. It’s no bad thing to start thinking now about how to deal with that resistance. (IRMA draws our attention to a Congressional briefing on PrEP on December 4th.) But let’s not get too far ahead of ourselves. There’s no point cashing in political capital in favour of PrEP until we’re sure it works.

Condoms lead to death, apparently. Since one in 10 adults in Dar is infected with HIV, you might think it more likely that unprotected sex leads to death. But perhaps to the Catholic fundamentalist who put up the posters, passing on a fatal virus is preferable to the sin of using contraception.

At the time, I wrote that “The Condoms = Death campaign … marks a shift in rhetoric from anti-abortion to anti-contraception among a small but vocal core of conservatives in the United States. Unless something is done about it very soon, that shift is going to be imposed on millions of women and men across the globe.”

It now looks like the first victims might be women on the home front. Under new regulations proposed by the US Department of Health and Human Services (pdf), many popular forms of hormonal and indeed mechanical contraception can be re-defined as abortion. And the legislation allows people who work in tax-funded clinics to refuse to provide those contraceptive services if it offends their delicate religious sensibilities. So much for separation of church and state.

Essentially, Conservative Christians, who’ve spent decades perfecting the use of the anti-abortion hot-button, are beginning to conflate contraception with abortion in much the same way as they’ve conflated prostitution with human trafficking. They don’t try to hide it: Human Life International, the Virginia-based Catholic organisation which is responsible for the Tanzanian posters, declares “We exist…to fight the evils of abortion, contraception, sex education and family breakdown”.

If this becomes entrenched in the States, it will certainly get exported around the globe. The AIDS funding legislation before Congress already prohibits the use of HIV prevention money to support contraception for infected women. We’re willing to give a pregnant women expensive antiretrovirals to prevent her passing HIV on to her infant, but we can’t give her cheap contraceptives if she’d rather avoid being pregnant in the first place.

It’s shocking and completely irrational. Though perhaps they’re just following the lead of the World Health Organisation. When I was last on a WHO contract the health plan wouldn’t pay for contraception, but it would pick up the tab for an abortion. Ho hum.

For more details on the US legislation, see Amie Newman and Cristina Page.

Now, wiriting in The Lancet, Dr. De Cock has corrected the correction, with the help of Paul Delay at UNAIDS. The facts are the same as those he gave in the original story. But they are hedged about with just enough “yes, buts…” to make them politically correct, too.

Kevin de Cock has now put his name to a mealy-mouthed UNAIDS/WHO press release which is billed as a “correction” to a story in The Independent last week, which quoted him as saying:

“It is very unlikely there will be a heterosexual epidemic in other countries [outside Africa]. Ten years ago a lot of people were saying there would be a generalised epidemic in Asia – China was the big worry with its huge population. That doesn’t look likely.”

The “correction” doesn’t actually point to any errors in the original story. It doesn’t say Dr. de Cock was misquoted. It doesn’t provide any solid evidence that he is wrong. Instead, it comes out with technically correct but completely irrelevant gems such as this:

“Heterosexual transmission continues to drive the epidemic among sex workers, their clients, and their clients’ partners. In addition, prisoners, injecting drug users, as well as men who have sex with men, may also engage in heterosexual relationships.”

My earlier flippancy notwithstanding, I was genuinely pleased by the story in The Independent. Dr de Cock had started to chip away at the wall of institutional self-interest known as UNAIDS, a wall that requires HIV to be an on-going threat to all of humanity. He had told it like it was; describing a problem accurately is surely a precursor to dealing with it effectively, something that he has been trying to do in difficult circumstances for many years. Apparently, those inside the wall of self-interest twisted Dr de Cock’s arm hard enough to put him out of action. I can think of no other reason that he would put his name to this kind of tosh.

Laurance quotes Kevin de Cock, a thoughtful and honest scientist who happens also to head up WHO’s HIV division, as saying “It is very unlikely there will be a heterosexual epidemic in other countries [outside Africa]. Ten years ago a lot of people were saying there would be a generalised epidemic in Asia – China was the big worry with its huge population. That doesn’t look likely.”

While it’s not clear in what context de Cock made the comments, Laurance describes them as “the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected”.

Regular readers know that I specialise in railing against spending HIV prevention money on populations that were never at risk in the first place. And I believe that the UN organisations have been at fault for “beating up” the epidemic to make it look as though everyone is at risk. So I could just claim that this is a vindication of what I’ve been saying all along. But to be fair, the story is itself a little bit of a beat-up. Careful readers of the epidemiological sections of WHO/UNAIDS reports will see that they have for some time now tried to draw a distinction between the epidemic in sub-Saharan Africa and that in the rest of the world. It is the other UN organisations that are “co-sponsors” of UNAIDS that gain more from the “everyone is at risk” mantra. The agencies that deal with young people and education and migration and labour and whatnot, the ones that want to get their snouts in the AIDS funding trough without really getting down and dirty with sex and drugs.

Is de Cock saying anything we didn’t already know? No (although his comments continue to excite a bit of comment in the blogosphere, at the WSJ online for example, Slog, and Sweetness and Light. Is his admission a big reversal of WHO policy? Not really. Does it allow me (and many others who have been banging the same drum) to say “I told you so”? Absolutely!

One of WHO malaria overlord Arata Kochi’s complaints was that the Gates Foundation is becoming a monopoly, squeezing out discussion and debate. Scientists are so desperate for Gates money, Kochi suggests, that they won’t speak truth to (purchasing) power. It happens that I am in Bangkok just now, at the invitation of the Gates Foundation’s HIV division, to talk about Foundation’s future contribution to HIV prevention. The handful of people invited are all independent thinkers with a lot of coalface experience researching and preventing HIV. None of us are shy, and none of us are after Gates funding. We chewed over our failure to deal effectively with HIV and spat out the unwillingness of governments from rich countries and poor countries alike to do helpful things on a large scale for sex workers, drug injectors and gay guys.

The Gates Foundation is not accountable to those pussy-footing governments, and it has lots of money. The WHO dances to the tunes played by the 192 governments that sit on its board, and it is skint. Which organisation do you think is most likely to be able to do what’s needed to stamp out HIV?

Update on the malaria debate: Kochi says Bill and Melinda Gates are unrealistic to call for the eradication of malaria. Setting unrealistic goals in not helpful, he maintains. I agree with him. But then I don’t work for an organisation that said (in 1977) that it would achieve “Health for All” by the year 2000.

Is Gates really a bully, or is the WHO just cross that it’s not the biggest boy in the playground any more?