AIDS

No carnival
Jul 28th 2005 | RIO DE JANEIRO

AP

AIDS treatment is more widely available than ever-but efforts are
needed to stop people becoming infected in the first place
Get article background

CUTTING bits of healthy tissue off a human body is not normally
recommended. People evolved into human form for a reason, so it is
probably best left alone unless there are good arguments for messing
with it. But in the fight against AIDS, anything is worth a try-even
circumcision. And, according to a trial whose results were announced at
the latest international meeting on AIDS, circumcision works. Indeed,
it works so well that the trial's organisers, France's National Agency
for AIDS Research (ANRS), felt obliged to stop it half way and tell all
the participants, so that those in the control group could get
circumcised, too.

The Third Conference on HIV Pathogenesis and Treatment, to give its
full name, is a reaction to the huge international AIDS conferences
that are held every two years. Those meetings, which started as
scientific workshops, have become jamborees and platforms for activists
to bite the hands of the donor governments and drug companies that feed
them. The International AIDS Society, which is responsible for
organising them, thus decided to fill the gap-year with a purely
scientific meeting, give it a long-winded and off-putting title, and
hope that the activists wouldn't notice. In this it has, by and large,
succeeded.

But even scientists like a dose of excitement and Bertran Auvert, the
head of the ANRS trial, administered this conference's fix of that
particular drug. It has been suspected for two decades that
circumcision might protect against AIDS. At first, this was because
infection rates in areas where the practice is routine are often far
lower than in apparently similar places where it is not. Subsequently,
it was found that the foreskin is rich in cells whose surfaces are
covered with proteins that allow HIV to lock on to them and force its
way inside. And after that, a number of direct comparisons of the
circumcised with the uncircumcised suggested the procedure really was
effective.

But looking at those who have been cut because they or their parents
chose it is no substitute for a proper clinical trial that cuts or does
not cut its participants at random. The ANRS study, one of four such
trials begun in Africa a couple of years ago, grasped the bull by the
horns. It took a group of uncircumcised and uninfected South African
volunteers and gave half of them the snip. By the time the trial was
stopped it was apparent that for every ten uncircumcised men who had
become infected, only three of the circumcised had succumbed, even
though only half of the volunteers had at that point participated for
the full 21 months originally envisaged.

Dr Auvert's trial-which, everyone was keen to emphasise, needs to be
backed up by others-is part of a reaction against the prevailing
ethos of AIDS, which is to treat it rather than prevent it. As Bernhard
Schwartländer, of the Global Fund to fight AIDS, Tuberculosis and
Malaria, observes, prevention has no lobby. Only those already infected
become activists. But only prevention will stop the epidemic.

The past few years have, indeed, seen the treatment campaign against
AIDS accelerate. The distribution in poor countries of anti-retroviral
drugs, which keep the symptoms of AIDS at bay, is proceeding apace.
Admittedly, it is not going at the pace that the World Health
Organisation would have liked. The WHO's bosses wanted 3m people to be
on these drugs by the end of this year, but that number will not be
achieved until the end of 2006.

In this game, however, if you hit your target on time it probably was
not ambitious enough. Anyway, the G8 meeting in Britain earlier this
month provided a new target. The meeting's participants announced they
were "aiming for as close as possible to universal access to
treatment for all those who need it by 2010".

Admittedly, this bold objective includes the weasel phrase "as close
as possible", which provides useful political wriggle room. But it is
still a hostage to fortune, and one that AIDS activists, not known for
their reticence, are likely to keep reminding governments about.
Indeed, Jim Kim, head of the WHO's HIV and AIDS programme, got the ball
rolling by telling the meeting's participants that it was now up to
them to come up with a "road map" that would allow the G8 aim to be
met. He wanted that map, he said, before next year's World Health
Assembly in May.

There is a risk, though, that if drug-delivery programmes are rolled
out willy-nilly without accompanying transmission-prevention
programmes, they will eventually make the situation worse. This risk is
the object of furious debate, not least because there are very few
data. But it is plausible enough to worry about, and it comes in two
parts. The first is that sloppy adherence to drug-taking regimes will
cause drug-resistant viruses to emerge. The second is that those on
drugs, feeling themselves to be better-and even, possibly, immune to
further infection-will engage in the sorts of risky behaviour that
infected them in the first place. Several mathematical models discussed
at the conference suggest that, without a parallel advance in
prevention techniques, the spread of effective treatment might even
increase the spread of the virus.

One way to combat this risk is to use the network that is being put
into place to deliver treatment to preach the message of prevention.
Another, which is just as important, is to find out which prevention
techniques actually work. There is still, for example, argument about
whether it was the wider use of condoms or a reduction in promiscuous
sex that curbed the epidemic in Uganda, even though that curbing is
held up as one of the successes of the global anti-AIDS programme.

At the moment, condoms and fidelity are indeed the only prevention
techniques around (unless like the American government, but unlike most
workers in the field, you regard preaching abstinence as a sensible
option). And, until recently, there was little prospect of that
changing. As Dr Schwartländer said, prevention has no lobby. The
trials are long-winded, as they have no clear end. They rarely involve
patented (and therefore lucrative) products, so industry is loth to pay
for them. And they require huge numbers of participants to get a
statistically meaningful result.

Nevertheless, trials of new techniques for preventing transmission are
starting to happen. A vaccine, sadly, seems as far away as ever. But,
besides the circumcision trials, there are trials on the
infection-preventing qualities of cervical diaphragms, on a vast range
of vaginal microbicides (not all of which also act as contraceptives),
on acyclovir (a drug that suppresses genital herpes and, with it, the
sores that give HIV access to the bloodstream) and on tenofovir (a drug
that is used to treat HIV infection and is now being tested to see if
it can act as a prophylactic). Several of these trials are expected to
report in 2007, just in time for the next meeting.

New prevention techniques will not be a panacea. In particular, if they
do not provide 100% protection, they risk encouraging risky behaviour
that would spread the virus. But if used sensibly, they should help to
stop transmission in a way that treatment never can. Perhaps,
therefore, the organisers should change the name to the Conference on
HIV Pathogenesis, Treatment and Prevention. By 2007, the P-word might
even be fashionable.

http://economist.com/PrinterFriendly.cfm?Story_ID=4221484

Those with a religious or emotional bias against circumcision will
reject the scientific evidence. And, by assimilating male to female
"circumcision", obscure the real issues:
http://www.lpj.org/Nonviolence/Sami/Art-Index.html

Condom use is even more effective. And it prevents other STDs.

Jeff