Four major misconceptions about the global HIV/AIDS epidemic
The following is a guest post by Daniel Halperin, who is on the faculty of Harvard School of Public Health and is finishing a co-authored book on AIDS. The opinions expressed are his own.
During the biannual International AIDS Conference this week in Vienna, there will be a strong push to increase funding for HIV/AIDS, along with calls to focus more on prevention of it. Given the poor track record of technological advances in HIV prevention, there is eager anticipation about a possible new vaginal gel that could help protect women from getting the virus. While future possibilities, such as the gel, and rhetoric in Vienna are well-intentioned, some of the assertions about AIDS are quite flawed. Here are four key misconceptions about AIDS:
1) Providing AIDS medications to everyone is the best prevention method. A new buzz phrase in the AIDS world is the “test and treat” notion. Some mathematical models have suggested that if tens of millions of people across Africa were tested for HIV, and everyone who tested positive was immediately placed on life-long antiretroviral medications, it would eventually end the epidemic. Such assertions are financially unrealistic, and rely on extremely optimistic and flawed modeling.
Real world evidence, in places such as America and Europe, suggests that although widespread treatment probably helps to reduce the infection rate, it does not eliminate it. So, instead, we should provide life-saving drugs to the people who urgently need them, rather than diverting expensive drugs, which can often have serious side effects, to millions of otherwise healthy individuals for a mainly speculative prevention benefit.
Preliminary research about potential “antiretroviral vaginal gels” will be presented Tuesday in Vienna. Such approaches could eventually help protect some women but, like condoms, they would need to be applied each time prior to sex. The gels may also have long-term toxic side effects and carry the risk that people will stop using more effective methods, like condoms or mutual fidelity, on the assumption they are now “protected” against HIV.
2) Behavior change doesn’t work. Some long-standing prevention approaches, such as condoms, are effective at reducing risk, though the actual impact of programs vary considerably depending on the nature of the local epidemic. In countries where the driving force of AIDS is sex work, such as in Thailand or Cambodia, “100% condom” promotion programs have often been quite successful at reducing the rate of new infections.
In the much more severely affected countries in southern Africa, however, there is less indication that the heavy investment in condom programs has slowed the epidemic. That’s mainly because it is notoriously difficult to maintain consistent condom use in the more long-term – and often overlapping – sexual partnerships where most HIV transmission in Africa occurs. Thus, in such settings it is crucial to also promote having fewer sexual partners.
3) There are no magic bullets. While this statement is certainly true, it masks another important truth, which is that the international prevention community has generally done a dismal job of prioritizing the best way to prevent HIV. The new mantra in the HIV world is “combination prevention,” which means let’s keep doing what we’ve been doing. Sadly, while many of the standard approaches, such as HIV testing and counseling, have important public health benefits, they have not been shown to reduce HIV infections in any major way.
By shying away from prioritizing the most effective interventions, some newer and potentially powerful approaches may not receive the attention and resources required to help stem the flow of new infections. Male circumcision, for example, is not as effective as condoms in reducing risk for each sex act but it lowers lifetime risk by at least 60% and confers protection every time a man has sex.
On that front, there has been some good news lately. In the part of western Kenya, where President Obama’s father was born and which has been the most severely affected by AIDS, more than 100,000 men were circumcised last year. President Zuma of South Africa has also recently endorsed the procedure, which his ethnic group, the Zulus, abandoned two centuries ago.
Moreover, and especially in the current global economic recession, there is an urgent need to pursue the most cost-effective strategies, such as male circumcision. There is not sufficient funding to “do everything” to prevent — and treat — the millions of new HIV cases continuing to occur each year.
4) HIV/AIDS is different from all other epidemics. At the end of the day our objective should be healthy people, and HIV is just one of many diseases. AIDS is not the overriding health problem in most poor countries, where more-mundane problems such as lack of access to clean water overshadow it. HIV/AIDS receives billions of dollars in foreign aid annually. Meanwhile, diarrhea and pneumonia kill many more people globally yet receive a tiny fraction of aid. Luckily, the Obama administration and others are increasingly realizing the importance of finding ways to leverage HIV/AIDS funding to improve overall health.
While we must continue to search for new technological approaches, let’s not forget that millions of lives have already been saved through using basic prevention approaches and common-sense changes in behavior.