Treatment is prevention. And black is white

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.

This post was published on 20/05/08 in Ideology and HIV, Money and AIDS.

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  1. Comment by Chuck Bird, 21/05/08, 03:04:

    “Wouldn’t it be better to invest more of the money in making sure that those people never need treatment in the first place?”

    That is true but the issue is how to prevent people getting infected in the first place.

    The sexual revolution started with the event of the pill because condoms were not all that effective in preventing pregnancy.

    The reason why HIV is so prevalent in the homosexual community is because homosexual lobbyists give untrue information about the effectiveness of condoms. Condoms are only 80% effective in preventing HIV infection. As long as homosexuals continue on average to have a high number of sexual partners the rate of HIV amongst homosexuals will remain many times higher than for heterosexuals particularly if immigrants are excluded.

  2. Comment by Chris Green, 21/05/08, 01:00:

    I do wish that those who continue to scream for more efforts in (and funds for) prevention could start to demonstrate even a smithering of hope that prevention really works, other than (perhaps) in the very short term. Although we beat up (pace, Eli) all the great advances that are going to occur Real Soon Now in vaccines and microbicides and so on, let’s admit that the truth is that we’ve made little progress in prevention in the 25 years since we discovered the cause of AIDS. Face it, condoms are not the solution; at best they’re a bandaid.

    Can anyone tell me why we never seem to add F & M to our ABC: Frottage and Masturbation (both individual and mutual)? I’m old enough to remember when these were still considered sex (not that we used that term either as far as I can recall!).

  3. Comment by Chris Green, 21/05/08, 01:06:

    BTW, in response to Chuck, there are those who would suggest the the sexual revolution started with a cure for syphilis. Prior to penicillin, syphilis was even more feared that AIDS is now. Hence frottage and masturbation…

  4. Comment by Mark, 21/05/08, 02:41:

    @ Chris Green – for our younger readers, I think that “frottage” may be better known to you as “dry-humping”. Perhaps a lost art? (Much to the relief of laundry workers everywhere, I suspect)

  5. Comment by Chuck Bird, 22/05/08, 12:12:

    Chris, I googled “sexual revolution” and mostly found the time it was meant to start was in the 1960’s. In any case that was peripheral to my main point about the reliability or maybe more correctly the unreliability of condoms in stopping the transfer of the HIV virus.

    If was traveling overseas to a country where serious disease was prevalent and was told an inoculation was 98% effective when it was 80% there would be an outcry.

    This is the case with condoms. Sexual health information should be truthful not political correct spin.

  6. Comment by Veritee, 23/05/08, 08:22:

    In the very short time I have known that I have HIV – since Jan 08 – I have too realised that’ treatment is prevention’
    That this IS the only way forward for all with HIV and in the fight to prevent and contain this thing – as if you are stable on HIV meds you are less likely to pass it on to anyone else – FACT!!!!.

    Both for me as an individual and for everyone else i.e. HIV in general
    Without HIV medication – you do eventually die of HIV

    With HIV medication and treatment

    You may live – and live to enjoy your life, at least for the time you have given you have HIV- and – importantly- Not pass it on to anyone else!
    Without treatment you will die – and feel damn ill in the meantime
    Heterosexual woman, live in the UK, diagnosed with HIV – probably have had it at least 7 years without knowing. Married to the same man for 21 years – never had sex with anyone else in 25 years – never taken any knowing risk for HIV – nor did my husband realise he had – so did not realise we had HIV until he had AIDs related infections
    Knowledge and treatment is all in the fight against this thing.
    Also we are VERY lucky enough to live in a country where you can get the latest drugs like we do – this also helps a LOT

  7. Comment by David, 30/05/08, 06:24:

    Whoever thinks condoms are only 80% effective have their head buried in the sand. I have worked in HIV education for 15+ years and they are indeed 97% effective when used correctly and every time you have sex. The 80% effectiveness information was borne out of the minds of religious zealots who want to control a religiously motivated political agenda when it comes to HIV and AIDS. Abstinence only cronies coming out of the woodwork screaming that condoms are only 80% effective does not help the conversation or the possible solutions. It just wastes valuable time.

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