“Test and treat” won’t beat HIV, says the witch

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.

Picture 1

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?

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This post was published on 24/02/10 in Pisani's picks, Science.

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  1. Comment by peripheries, 24/02/10, 11:16:

    I got an even better figure than yours, but a different explanation as why it could not work, even if I think it is the future!

  2. Comment by Conor, 25/02/10, 12:15:

    I completely agree with what you have said there. As a gay man I know that a lot less people are using condoms due to an apparent decrease in the risk of HIV killing you. I have spent countless hours (including many last night) explaining some side effects of drugs and how 1 pill a day is possible but its still 1 pill every day for the rest of your life which will sill probably be considerably shorter than if no HIv transmission had taken place. As I do HIV research myself I see how the drugs are improving quality and length of life and fighting the disease, I still think that if people didnt get it at all in the first place we wouldnt need better drugs, we wouldnt need drugs at all.

  3. Comment by Pheasant, 25/02/10, 02:43:

    Pisani always looks at facts and arguments. I think she looks at them from many points of view. The people who whine and complain about her seem more concerned about appearances and maybe, accidentally offending someone. People are going to be pissed by her findings, but get over and start working toward some solutions.. this is HIV we are talking about people.

  4. Comment by Sahil, 25/02/10, 04:57:

    [this comment is on thebathhouse as well]

    I think the original article helps raise anthropologists’ favourite issue – practice. Is it more fruitful to think of ‘development ‘as policy statements – such as blanket testing and treatment for all – or practice.

    The development industry has to be more concerned with policy statements that mobilise funding and the support of a diverse set of interest groups – NGOs, Governments, Electorate, WTO etc – than about how policy unfolds when it’s implemented.

    What the article help’s articulate is that policy is undermined by all sorts of mundane human factors. To maintain ARV treatment you need to eat etc, you need to make it to the clinics regularly etc. This doesn’t, in itself, undermine the policy prescriptions, but I think the gap between policy and practice is not thought about enough when considering development intervention.

    From my perspective development is, like everything, a case of competing interest groups. Policy is a tool to align some interest groups, which by definition, marginalises others. I don’t know enough about the development health industry, but I guess a policy of blanket testing and treatment will be fantastic news for Big Pharma and other health-delivering organisations, alongside having plenty of other consequences.

    This is all very obvious and it doesn’t undermine the policy, but 50 years of evolving policy statements have had pretty unsatisfactory development outcomes, so how else can we think about it all?

  5. Comment by Miriam in Vancouver, 26/02/10, 12:20:

    Thank you for sharing Elizabeth. Our media in BC has been so biased in favour of Seek & Treat (treatment as prevention) that we were thrilled to have some concise and concrete arguments about the challenges. Funny when we talk about education, behaviour change, and getting condoms where they are needed, we are called utopian. And here, we are supposed to believe that somebody is going to (pay to) test every person (in Africa? In the world? …) and then (pay to) treat everybody who tests positive? There are two arguments that convince me we should not put all our eggs in this basket:
    1) there is evidence that treatment might NOT actually reduce transmission in anal sex, and no convincing evidence that it reduces transmission in IDUs. Let’s not forget that anal sex (gay or not) and IDU are still the main ways this virus travels rapidly through populations; and
    2) when somebody is most likely to transmit the virus (right after infection), they are likely to be in the window period and test negative. By the time they test positive and receive ARVs, they may already have infected many people.
    Yes, we need increased testing!
    Yes, we need increased treatment!
    But this does not replace the need for increased prevention education, access to condoms, etc.

  6. Comment by Kees, 02/03/10, 01:39:

    You wrote:
    “We DO, however, need to face the fact that until now, more treatment has been associated with more new infections.”

    What about the recent neuws from British Columbia and San Francisco?
    It looks like an association between more treatment and less infections.

  7. Comment by rogerq, 03/03/10, 11:52:

    The SF data in gay men are not statistically significant. Community viral load was not associated with a reduction in HIV incidence.

  8. Comment by Rupert Gude, 30/04/10, 12:01:

    Dear Elizabeth,
    I have just read the responses to your excellent article in the Guardian. I was appalled at the rudeness, the poor counter arguements and the ignorance of many of the respondents.
    I have just spent 15 months working in an HIV outptients in Tanzania. Your article is spot on. Even with high prevalence rates and open access to testing it is extremely difficult to persuade people to come to be tested. The men were particularly resistant until ill. Even if tested positive a third dissappear without trace becauce of stigma. In our antenatal clinic only a quarter would qualify for ART due to CD4 below 350 and half of these defaulted as they felt well. ART adherence was extremely good in our patients especially the women but there did seem to be a trend to default if initial symptoms were mild.
    As you have described before many AIDs experts grow fat on their AIDS work which has little revalence to those working at the coalface.
    Keep up the good work

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