Monday, 13 June 2011

The Economist suggests the end of AIDS? Really?

Article first published on blogging site the 21st Floor 

So, it’s 2011, and it’s the 30th birthday of AIDS. Not much to cheer about there, although it is a convenient point to reflect on the impact of this devastating infection, to scan the horizons to see what might happen in the future,  and to push for even greater investment and collaboration in the future.

The Economist has run a leading article entitled “The end of AIDS?” with the sub-heading “Thirty years on, it looks as though the plague can now be beaten, if the world has the will to do so”
Now, let me be so bold as to suggest this is massively over-stating the case of our progress in the battle against this most ingenious of retroviruses.  Yes, we have seen huge improvements in the standard of care, the provision of better and better drugs (one-a-day pills trumping the previous cocktail of drugs sufferers used to have to take daily), greater understanding of the virus genome and immunological response. But to head the article with as grand a statement as “the end of AIDS” is nowhere near the truth.

The Economist says that “the war on AIDS is going far better than anyone dared hope”. I would say that 30 years ago, knowing that  30.8 million adults and 2.5 million children were living with HIV at the end of 2009 would not have featured in too many experts’ best-case scenarios. The Economist gives one reason for their optimistic approach is as “the death rate is dropping”. This is true, and cause for good cheer – but limit yourself to half a pint, as there is work and thinking to be done. A dropping death-rate, whilst of course A Very Good Thing, also means there are more people alive with the virus (especially with around five million new infections each year). More people to look after in stretched or non-existent healthcare facilities, and more money needed to spend on life-saving drugs. The burden transfers from how we can keep these people alive, to how we can look after them now we’ve kept them alive in the first instance. The latter is preferable to the former, but it’s one heck of a challenge. Especially given so many of those infected are living in low-income countries, which are not remotely prepared or able to deal with it.

So, what to do? Well, a vaccine would be nice. The finalisation and approval of this Holy Grail of medicine would go a long way to justifying a headline such as “The end of AIDS?”. But any vaccine is many years away, and certainly not on the horizon. It is over the horizon, and much further along a maze of winding roads – we do not yet know quite which is the road that leads us to the Emerald City, or how far it is. There have been promising initial studies on vaccine research previously, and they have ended up a disappointment; work continues around the world to build on these failures and try to generate a genuine, and massive, positive angle to this.

What else is there? Antiretroviral drugs are improving all the time, but whilst they suppress the viral load, thus reducing risk of transmission, they are not designed with prevention in mind. Microbicides are an interesting approach – they are essentially topical drugs that can be smeared inside the vagina or rectum, and act there as anti-infectives. Trouble is, we are still at the ‘promising study reveals hope’ stage for these too, such as the CAPRISA study or another candidate (also reported in the Economist, June 2011). And once we have a reliable microbicide in however many years from now that would be, it needs to be provided to every country around the world, it needs to be accepted by the public and not treated with suspicion, and women need to learn to how apply it and how to be empowered by it.

Which brings us onto another huge segment of the problem - behavioural.

Yes, the typical behaviour of mankind is not ideal for stopping a global pandemic of epic proportions, no matter how clever the medicine, what with our propensity for promiscuity, lack of safe sex and a lack of promotion of safe sex (are you reading this, Benedict?*), rape, poor education, attitudes to HIV itself, attitudes to associated stigmas such as homosexuality, and so on. Entire behavioural and cultural shifts are phenomenally difficult to introduce, and take a long time.

The Economist article is mostly very well written, being both interesting and thought provoking.  But winning the war on HIV and AIDS? At best, we’re in a stalemate at the moment. A very long stalemate. It should get better – but it will take a long old time and at huge cost (mortality, morbidity and economically) to mankind.

Michael Head

* I reckon probably not

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