Thursday, July 1, 2010

Test All, Treat All for HIV: Just Another Shot in the Dark

The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.

The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.

The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.

Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.

Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.

In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?

The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.

But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.



Mark Lyndon said...

Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

It's not like we've actually tried the things that do work. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

Simon said...

Mark, thank you for your comments, indeed, there has never been any consistency in correlations between HIV prevalence and circumcision. Sometimes they seem to correlate, sometimes they don't.

However, the point I was making was that not all HIV transmission is sexual, which puts a question mark over other interventions in addition to circumcision, which assume sexual transmission.

Calling circumcision a vaccine or anything else like that is very foolish, but no more foolish than calling education a 'social vaccine' against HIV, a term some people seem to be fond of. It has never been one. Correlations between HIV prevalence and education have varied over the years but have never shown clearly that education on its own is going to reduce transmission substantially.

If you look through some Demographic and Health Surveys, that will be confirmed for you. And while you're there, also check the correlations between abstinence, 'faithfulness' and even condom use. You will find the same thing, that they don't appear to be unambiguously successful in reducing HIV transmission. Often, the figures suggest the opposite.

Your argument that circumcision doesn't work are undermined somewhat by your advocating other strategies that also don't work. But your argument could suggest that the 'behavioural paradigm', the belief that because most HIV is transmitted sexually transmission can be reduced by changing people's sexual behaviour, is wrong.

There is very little correlation between people's knowledge about sexually transmitted HIV and their sexual behaviour. And there is very little correlation between people's sexual behaviour and HIV prevalence. You can choose to ignore evidence that suggests that HIV is not always transmitted sexually but it doesn't really help your argument in the long run.

I agree that sexually transmitted HIV needs a different strategy (certainly not that sexually transmitted HIV should be ignored) to non-sexually transmitted HIV but the industry won't even admit that the latter exists. Until they do, circumcision will have as little positive impact as any other strategy and probably more negative impact.

> There are African prostitutes that sleep with 20-50 men a day

I have heard similar claims but I have never seen any data suggesting that this is even possible. 50 per day means just over 4 people an hour on a 12 hour day. That sounds like a logistical nightmare, and pretty bad value for all the parties involved. If you have any published papers on that, I'd love to see them.

Simon said...
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Mark Lyndon said...

"50 per day means just over 4 people an hour on a 12 hour day. That sounds like a logistical nightmare, and pretty bad value for all the parties involved. If you have any published papers on that, I'd love to see them."

I can only quote one published paper, but think the logistics of prostitution in Africa are very different to how you imagine. I don't think 50 clients a day is unrealistic at all, and the "service time" for women having sex that often is a lot shorter than 15 minutes. I can't find the article I was looking for, which was talking about conditions at a particularly busy truck-stop, but here are some other links talking about what's possible (two links no longer work, and sadly I don't have copies):
(article about a woman in Nairobi who appears to be immune)
"On an average day, she might entertain five or six clients. On a good day, 10. In the course of her career, she has probably had sex more than 50,000 times. The encounters are basic – lasting around two minutes each…"

This link (now dead) talked about up to 30 clients a day in India:

This study was in Kenya:
"some of the sex workers have up to 30 clients per day"
"20 to 30 clients per day" (India, dead link)
"The establishment has six in-house sex workers, who see an average of 30 clients a day" (Mozambique)
"Each woman serviced from 15 to 60 clients a day." (Japan’s "comfort women" and GI’s)
"Some had been forced to "service" up to 60 clients a day." (trafficked women in the UK)

Mark Lyndon said...
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Mark Lyndon said...
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Mark Lyndon said...
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Mark Lyndon said...

(Sorry about the removed posts. When I originally tried to post, I got an error message, so I thought it hadn't gone through, and split the post up into smaller pieces.)

Simon said...

Hi Mark. Ok, I see where you're coming from now. I hope you use more credible sources of information for your circumcision research.

These sources are all just reportage with no peer reviewed papers or checkable data cited but the Telegraph one was by far the worst. It's riddled with inaccuracies.

Kenya's 'rate' (I'm assuming they mean prevalence) is not the highest and never has been. The figure has never been 25% and the estimates are not now, nor were they in 2006 when this article was written, 15%. The highest national prevalence in Kenya was probably 10 or 11% back in the late 1990s. Prevalence in 2006 was about 6%, which is still very serious.

Among women who sell sex, prevalence is not 80%, though it was found to be around that level in 1986. No adequate explanation has ever been given for this but suspected is a sexually transmitted infection programme, which could have spread HIV among participants. This is speculation, by the way, the sort of thing the Telegraph may publish as fact!

Surprisingly, the Telegraph says "Many are considered unreliable witnesses to their own lives" and "Tens of thousands of other poor, rural Africans have the same idea [of moving to Nairobi to do sex work] every year, and competition for the few jobs available is tough." If competition for work is tough and there are many women, it would be surprising if some women were getting 50 clients a day.

There may be all sorts of aspects to the sex industry in East Africa but I have spoken to many women who work in the business. I have never met any who claim to have had so many clients in a day, even in a week. Nor have I met any who claim to earn so little, although some have said that there are women who earn so little.

If these 'tricks' are taking two minutes, does penetrative sex even take place? I really wonder where some of this stuff comes from. Even the one from Plusnews doesn't make it clear if the six workers have 30 clients a day or if each of them have 30. But this article also is just reportage, with no links to data or peer reviewed papers.

The Medical News Today article refers to data but only gives a link to a university web site. The human trafficking site has a disclaimer saying that the articles they cite have not been checked and they cannot guarantee their accuracy. Trafficking, and the 'comfort women' referred to in another article, would seem to be quite different from the kind of sex work the others are talking about.

If you want your remarks about male circumcision to have any credibility you need to reduce your dependence on newspaper articles, which tend to cite other articles of equally low value and indulge in fantasy and speculation. I'm not saying no newspaper article has any worth but there are other and more reliable sources of information. If you've only read these things in newspapers I don't think you should be using them as arguments for something as important as medical safety.

Mark Lyndon said...

I use the most credible sources I can, and sadly prostitution isn't that easy to study. Some aid donors are opposed to targeting sex workers anyway, which makes it harder to find out what's going on.

The third link is about a study presented in 2006 at the XVI International AIDS Conference in Toronto btw:

I'm too busy to reply in detail now, but will post sources later for some of the other stuff I wrote.

Simon said...

Ok, but there are plenty of articles about sex workers on sites like PubMed, all peer reviewed. Thanks for the links.

Mark Lyndon said...

These are the links for the figures on African countries where men are more likely to be HIV+ if they've been circumcised:

Cameroon: table 16.9, p17 (4.1% v 1.1%)
Ghana: table 13.9 (1.6% v 1.4%)
Lesotho: table 12.9 (22.8% v 15.2%)
Malawi: table 12.6, p257 (13.2% v 9.5%)
Rwanda: , table 15.11 (3.5% v 2.1%)
Swaziland table 14.10 (21.8% v 19.5%)

This is the South African National Communication Survey on HIV/AIDS, 2009
"12-22% of men and 12-17% of women across age groups (15% in total) also believe that circumcised men do not need to use condoms"

Mark Lyndon said...

See also
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
"Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries."

This 1993 study found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

This is the Wawer study that showed a 54% higher rate of male-to-female transmission in the group where the men had been circumcised. The figures were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women. Somehow that's considered unethical, yet it's considered ethical to promote male circumcision whilst not knowing if the risk to women is increased (by 54%?, 25%?, 80%? - who knows?)

I'm not the only person questioning the promotion of circumcision btw:

French AIDS Council:
"Even though the WHO insists on the idea that, beyond male circumcision, the use of other forms of prevention remains essential, it is very likely that people who mistakenly believe themselves to be adequately protected will no longer use condoms."
"Implementation of male circumcision as part of a draft of preventative measures could destabilize health care delivery and at the same time confuse existing prevention messages. The addition of a new tool could actually cause a result opposite to that which was originally intended."

Rozenbaum W, Bourdillon F, Dozon J-P, et al. Report on Male Circumcision: An Arguable Method of Reducing the Risks of HIV Transmission. Conseil National du SIDA, 2007: 1-10.

and as this South African paper puts it:
"Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections."

Simon said...

Thanks Mark, I didn't suggest you were the only one objecting to circumcision. I, and many ohters object to it as a means of reducing HIV when there is so little evidence that it will do this.

I and others object to it because healthcare conditions in African countries are poor and not suitable for a mass male circumcision program.

However, the evidence used to object to circumcision should be sound, not hearsay, rumour and journalese.

I agree with your conclusion, I just don't think you argue for it very well and if circumcision were to be removed from the agenda, you would have little or nothing to put in its place. You've simply swallowed the pathetic arguments about the effectiveness of 'ABC' and similar programs. Even UNAIDS don't believe they work, they just don't want to admit that until they have something else to beat people over the head with.