HIV warfare: choosing the right strategy

I had a chance to participate in an “HIV warfare” simulation game in a business school class yesterday. It was pretty interesting—after a little background on the epidemiology and projections of the disease, we split into two groups: the private sector and the donor (NGO) community. I was in the first group, which was a good thing because I was a little confused about what the donor (NGO) community referred to (I would normally split those up, as donors have money and determine priorities, whereas NGOs are more likely to be implementing and have less influence).
I spend most of my time surrounded by people who are well informed about HIV and generally share my ideas about normative models of combating the disease. So, I was caught pretty off guard about how this bright but uninformed population thought about the disease. I thought I’d take the chance to offer some thoughts on what I think is well established, and some thoughts about how we could use this data to create more informed delivery models.
Separating prevention and treatment is a false dichotomy. A good program will deliver both. For a variety of reasons—people are more likely to get tested when treatment is available, stigma decreases as the diagnosis ceases to be a death sentence, BUT, treatment is expensive and preventing new cases of HIV is always a better solution. One article on PLOS medicine (open access) shows that with a combined approach, by 2020 we could potentially avert almost 30 million infections and reduce the number of people on treatment by more than 50%. As treatment has become available, relatively fewer and fewer resources have been available for prevention (in absolute terms, this may not be true. I will investigate. One article here talks a bit about funding allocation). It’s unclear as to why this is—some people say that it’s hard to measure successful prevention, whereas it’s easy to measure “number of patients enrolled on treatment” and similar indicators. Some say that the pharmaceutical company saw a huge opportunity and successfully changed the conversation. Simultaneously, many grassroots organizations had taken up the cause of people living with HIV/AIDS, both in the US and abroad, and they lobbied for treatment (one well know example is the Treatment Advocacy Campaign of South Africa). Fewer groups took up the cause of HIV-free people. For whatever reason, we’ve reached a point where treatment gets the center stage. I would argue that relatively minor investments in prevention could have great impact.
Even as I type that last sentence, I get a little uncomfortable with my confidence in our ability to do things well. HIV prevention is a HUGELY political area—HIV by its very nature requires society to think about it’s often marginalized or stigmatized populations: men who have sex with men, injection drug users, and commercial sex workers. Sex and drugs, two areas where controversies and politics are rife. Despite significant evidence that for concentrated epidemics (i.e. where HIV exists largely in certain sub populations and is not widespread) targeted prevention efforts can be very effective, politicians seem reluctant to invest in these strategies, preferring instead to educate school children and other “innocents.” This may relate back to the treatment preference, as the faithful wife who got HIV from her husband is more compelling image than the injecting drug user getting clean needles to prevent contraction of HIV. Some authors have argued that the decision to frame poverty as a cause of HIV has ultimately led to misallocation of funding and misdirected strategies. Indeed, in many countries, wealth is associated with higher rates of HIV. But, again, the full picture is obviously more complex. If nothing else, many women and men go into sex work for economic reasons (not the best cite, but some evidence). In that sense, poverty does put people at risk for HIV. Obviously poverty could prevent people from purchasing condoms, traveling to the clinic for HIV testing, or create delays and/or interruptions in treatment. But, at the end of the day, getting HIV requires one to engage in unprotected sex or injection drug use. It’s worth noting that at least in the U.S. populations, youth across all socioeconomic classes engage in “risky” behaviors at the same rates. The difference is how many potential infected partners exist in one’s sexual network. For the poor, minorities, and men having sex with men, that percentage is higher—for the former two in large part due to injection drug use and overrepresentation in the prisons. I say to just point out the fact that “risk” is relative—it’s easy to assume that Africans have more sex or poor people have less impulse control and thus don’t use condoms, but the data don’t support that. They just happen to be closer to more people with HIV. So, I would re-write the risk factors, personally, to include, “being in a neighborhood with a large prison population”, and other factors that are less focused on individual behavior. If you want cites on that, let me know. I wrote a 20-page paper about it my senior year of college!
I’m becoming more and more convinced that condoms are a really poor solution. There is little evidence to suggest that any group, any where, has really embraced them and uses them 100% of the time. With high-risk groups, such as sex workers, they are a great solution, but in the majority of cases (67% of HIV is in sub-Saharan Africa and has moved to a generalized distribution), traditional commercial sex is not how the disease is transmitted. It’s casual or serious sex partners, but usually under the auspices of a relationship. I hesitate to say too much because transactional sex, that is, sex explicitly in exchange for gifts or money, does occur with some frequently (for one in-depth look at transactional sex across 12 sub-Saharan Africa, go here). So, there is an economic dimension to sex that can’t be ignored, but by and large, sex is occurring in a context where there is trust or at least the expectation of trust, and there’s no evidence to suggest that condoms are a popular choice in those settings.
Final thought, and building on the last one, people are smart and care about their own survival. So, there’s no need to trick people into protecting themselves, and any effort that thinks withholding information will do the trick is patronizing at best, when it’s western experts deciding that Africans shouldn’t get the full story, it’s racist. All the even marginally successful HIV prevention success stories I can think of—Brazil, Thailand, Uganda, even the gay community in the U.S.—the solutions were locally developed. Uganda’s story is really interesting—the government actively promoted “zero grazing” (i.e. be faithful to your spouse(s)) and emphasized that condoms should be used as a last resort, versus a primary behavior change. The data is spotty, but it appears that young people delayed having sex for the first time, and most adults stuck with zero or one sexual partners. Condom usage remained low the whole time. HIV incidence fell dramatically. Western “liberal” “experts” (can’t resist the quotation marks) argue that partner reduction and fidelity are either impossible (which seems to imply that African men cannot control their sexual urges) or imposing morals on others (which we do all the time. Don’t we tell smokers not to smoke? Stigmatize drunk driving?). A lot of the discussion that followed the research demonstrating the efficacy of male circumcision as a HIV prevention tool (60% reduction over a two year period) was around the fact that people would assume that this was 100% effective and would thus engage in riskier behavior (example here). Part of me thinks that this is really context-specific; I’ve never heard anyone argue against making a heart medication available as fast as possible because they were worried that people who stop watching their weight and exercising. Discussions around rolling out the HPV vaccine to all teenage women in America was framed totally differently: let’s maximize protection and take full advantage of the preventive tools that exist. What’s the difference?