Are We About to Eliminate AIDS?

February 21, 2009 11:40 PM

New Scientist:

What if we could rid the world of AIDS? The notion might sound like fantasy: HIV infection has no cure and no vaccine, after all. Yet there is a way to completely wipe it out - at least in theory. What's more, it would take only existing medical technology to do the job.

Here's how it works. If someone who is HIV positive takes antiretroviral-drug therapy they can live a long life and almost never pass on the virus, even through unprotected sex. So if everyone with HIV were on therapy, there would be little or no transmission. Once all these people had died, of whatever cause, the virus would be gone for good.

It's a simple idea, but the obstacles to implementing it worldwide are enormous. Persuading everyone with HIV to start therapy purely for public health reasons could be ethically dubious. To identify everyone who is HIV positive would require such widespread testing that some may feel it breached their civil liberties. Then there is the question of who would fund such a massive undertaking.

Much much more in the article.

posted by andoatnp (49 comments total)

Just wait till the autism crusaders hear of this
posted by slater at 11:43 PM on February 21 [7 favorites has favorites]

Yogi Berra once said, "In theory, there's no difference between theory and practice. In practice, there is."

This particular proposal is an example of the difference between "possible" and "feasible". It's possible to do what they propose, in the sense that doing so would not violate the laws of physics. But there's no way it would be successful, and the negative side effects of the program would in some ways be worse than the status quo.

It's not just that the obstacles are enormous. They're prohibitive.
posted by Class Goat at 11:45 PM on February 21

It's not just that the obstacles are enormous. They're prohibitive.

Which obstacles are you referring to?
posted by andoatnp at 11:49 PM on February 21

I just noticed that. That's got to be more trouble than it's worth, no?
posted by dunkadunc at 11:52 PM on February 21

Is this supposed to be a post about drug patents and the reality medication adherence?
posted by mandymanwasregistered at 11:55 PM on February 21

But there's no way it would be successful, and the negative side effects of the program would in some ways be worse than the status quo.

What negative side effects? What are you talking about? Those drugs don't cost very much to make, the main problem seems to be education. Lots of people in the developing world don't seem to believe in that taking the drugs are a good idea, but what exactly would the downside in teaching people be?
posted by delmoi at 11:56 PM on February 21

You forgot the monkeys.
posted by weapons-grade pandemonium at 12:29 AM on February 22 [1 favorite has favorites]

So if everyone with HIV were on therapy, there would be little or no transmission.

Not all strains of HIV respond to current therapies.
posted by Blazecock Pileon at 12:37 AM on February 22

This seems like it would be as effective as just telling everyone with HIV to not have sex.

That is, not at all.
posted by aubilenon at 12:44 AM on February 22 [2 favorites has favorites]

When you say "At least in theory," you can say any fucking thing you want after that.
posted by longsleeves at 12:48 AM on February 22 [1 favorite has favorites]

andoatnp: Which obstacles are you referring to?

Well, let's see:

It would cost an absolute fortune, right when the planetary economy is all but collapsed.

Since HIV infection has no obvious symptoms, you'd have to test everyone on the Earth for the virus. That's difficult and is likely to be met with resistance from countries would consider such a thing an affront to their national pride (the middle east, etc.) Also, you have to find everyone in the world to test everyone in the world. Finally, you have to deal with the AIDS test itself, which doesn't have a perfect success rate and is subject to a window of failure during the early stages of infection, necessitating you test everyone on the planet twice.

Certain people are inevitably going to be allergic to the drugs.

Distributing anything to citizens in strife-riddled third-world countries is dangerous, difficult, and prone to failure. You're talking about distributing a drug that has to be taken for the rest of a person's life to people who can't necessarily even get food reliably - and then you have to trust these people not to trade them away.

Many people have been bought into illogical and fallacious arguments that these drugs are not helpful or even that they are the cause of AIDS itself. You won't be able to get these people to take them through any means but force, which is unfeasible and somewhat ethically questionable.

Some sufferers are too irresponsible to be trusted to take the drugs reliably.

'Little or no' transmission is not no transmission. Furthermore, you can reliably trust that many of the patients will abandon their previous safety measures (condoms, etc) when they've been told that transmitting the virus is unlikely.

You'll be selecting heavily for drug resistance.
posted by Mitrovarr at 12:55 AM on February 22 [17 favorites has favorites]

I think the question the articles raises is not whether this idea is practical or likely to happen in the whole world, because the answer to both of those questions is probably not so much, but whether this idea could be implemented in a single developed country, such as England. And if so, could this policy go from country to country, eradicated HIV, similar to the way other diseases were tackled region by region, and not the whole world at once.
posted by andoatnp at 1:23 AM on February 22

It would cost an absolute fortune, right when the planetary economy is all but collapsed.

You mean it would take a lot of work, right when lots of people are unemployed with nothing to do.
posted by delmoi at 1:28 AM on February 22 [2 favorites has favorites]

Also, you wouldn't really need to get everyone. If you get 99% of the cases, you can knock down the next 'generation' of AIDS victims by a similar number. As far as the middle east goes, there is hardly any AIDS there, so that's not a big issue.
posted by delmoi at 1:31 AM on February 22

whether this idea could be implemented in a single developed country, such as England.

The article specifically addresses that, at least from one expert's viewpoint:

For Brian Gazzard, one of the UK's leading HIV specialists, based at the Chelsea and Westminster Hospital in London, this makes elimination on a country-by-country basis unfeasible. "It's got to be done worldwide," he says.

posted by Rhomboid at 1:36 AM on February 22

Rhombold: Although the article mentions that there is some doubt about whether it could be successful in an individual country, there are some people who seem to think it is worth a shot:

Yet the idea of eliminating HIV is so appealing, and the benefit to humanity so huge, that scientists and policy-makers are seriously considering the concept, albeit on regional scales. In the next few months the World Health Organization (WHO) will meet to discuss how the idea could be tried in developing countries, and something approaching elimination might be attempted in the UK within the next decade. "You could eliminate transmission overnight," says Marcus Conant, an HIV specialist in San Francisco.

The results of what might happen in the UK would potentially have a major affect on how HIV is fought in the coming years.
posted by andoatnp at 1:49 AM on February 22

You'll be selecting heavily for drug resistance.

Quoted for truth. Let's not forget the virus is evolving, and likely to do so over the life of the most long lived hypethetical sufferer.
posted by Jilder at 2:10 AM on February 22 [1 favorite has favorites]

This talk of theory vs. practice reminds me of something that my school's Industrial Design program does (this may be a universal ID thing, I wouldn't know).
Whenever you are designing something which has components that do not actually exist yet (generally these are things that either exist only in theory ie: certain propulsion systems, etc., or do not exist in a mass-producible manner ie: carbon nanotubes), it is polite to put the initials p.f.m. in parentheses after the label in diagrams, so if you were designing something with a solar sail, the arrow pointing to the sail itself would read "Solar Sail [p.f.m.]"

This indicates the real-world feasibility of your product. While it may be able to be made in theory, to get and/or mass-produce these items for use in it would require p.f.m: pure fucking magic.
posted by The Esteemed Doctor Bunsen Honeydew at 3:09 AM on February 22 [5 favorites has favorites]

Impossible. One of the most fundamentally difficult "practical" problems in treating individuals who are HIV positive is getting them to adhere to treatment. Retroviral treatment regimes are complex. Many inidividuals who are HIV+ have difficulty maintaining the 95% adherence that keeps treatment effective. Taking pills 2,3,4,5,5 times a day, sometimes at the same time every day is difficult. Many clinics require training programs to practice adherence for at-risk patients before they even will dispense medication. The consequences of falling off the wagon are often mutation and losing the effectiveness of the cocktail, meaning treatment then must be progressed to the next effective cocktail, usually one with more side-effects. Non-adherence also, through mutation, creates more powerful, more resistent strains of the virus, that when passed on, are already more difficult to treat. When I did a two year policy research/tech writing stint at an AIDS clinic as a new grad student, and really had to learn about the "practical" barriers in treatment, I was told that one of the nightmare scenarios was the mass infection with newer HIV super-viruses created through non-adhering patients engaging in high risk behaviors. They were not effectively treatable with any class of drug developed at that time (4 years ago). It's articles like this that made their jobs more difficult through people who a voice and/or some power reading them and getting distracted from the issue at hand - making existing treatments available, finding a way to pay for them, getting people to take them, and evetually developing new ones.
posted by mrmojoflying at 3:56 AM on February 22 [5 favorites has favorites]

If what you are trying to do is reduce the number of humans from dying globally, it's probably more effective to invest in water and sanitation systems. Ethically, I fail to see why advanced science should be applied to treating AIDS, and basic science not applied to water and sanitation.
posted by a womble is an active kind of sloth at 5:45 AM on February 22 [7 favorites has favorites]

Come now, people and puppets, this is perfectly attainable if you aren't in a rush.

Clearly you can't wipe it out, and certainly not all at once, but a systematic program could reduce AIDS to the level that leprosy is, in a generation or two. If you can cut the spread of AIDS by x% per year, you can get it as low as you like.

You don't have to test everyone - you need to keep systematically sampling and then examining everyone "around" a victim when you find them.

There would have to be some civil liberties adjustments to allow people to be involuntarily tested. I'm not sure I like that idea. If it came in, there would have to be strict boundaries.

As for treatment, it'd be like testing - tiny incentives to do it, huge penalties if you don't.

And the whole way society treats AIDS victims would have to be different. If you categorized AIDS suffers into two categories:

1. angelic AIDS victims who are receiving steady treatment and are suffering for the good of society.
2. demonic AIDS criminals who shirk treatment and put all of humanity at risk.

you'd have to bet that the rate would drop to nothing in a few decades.

(This isn't like, say, child sexual abuse, where all the approbation in the world won't dissuade you from your sickness... because "having AIDS" is simply too abstract and intellectualized for more than a handful of pervs to fetishize...)
posted by lupus_yonderboy at 7:24 AM on February 22

The costs of "saving the banks" are prohibitive as well, yet here we are.
posted by tommasz at 7:38 AM on February 22 [2 favorites has favorites]

s far as the middle east goes, there is hardly any AIDS there, so that's not a big issue

Really? We have hard numbers on this? Is there a study somewhere you could link to?
posted by AdamCSnider at 7:49 AM on February 22

Really? We have hard numbers on this? Is there a study somewhere you could link to?

Ahmadinejad said this right after proving that Iran has no gays.
posted by Krrrlson at 8:00 AM on February 22 [1 favorite has favorites]

Well when I googled it I got a crapload of links. If you want to sort throught the 2007 UNAIDS report. This overview may be a little easier. Apparently, it's only about 1 percent of the worlds case load(2003, not including Africa), although the article is old the numbers look to be about same. But injectable drugs are quite popular, so is unprotected sex with prostitutes. The testing is erratic as is sexual behavior which most likely could throw these numbers off quite a bit.
posted by P.o.B. at 8:24 AM on February 22

Man appears free of HIV after stem cell transplant
posted by homunculus at 9:27 AM on February 22 [1 favorite has favorites]

The article is saying that we can get rid of AIDS the same way we got rid of tuberculosis.
posted by neuron at 9:33 AM on February 22

Interesting for sure. But as mentioned previously the biggest boulder in the way is convincing people that this is "for the best." Good luck with that.

As an aside, I'm dismayed that there's still so much misinformation about HIV even in the developed world. HIV is a difficult virus to transmit. Unprotected vaginal intercourse puts the male at a 1 in 2000 risk for contraction from an infected female. It's about twice that risk for the woman if the male is infected. Anal sex is much more risky, particularly for the receiver, around (IIRC) 1 in 100 or so. And if a condom is being used (and properly) your chance of infection is so infinitesmal you might as well worry about a meteorite beaning you in the head.

I tried explaining this to a friend of mine who was freaking out after a night of debauchery. He wore a condom, but had no idea of the HIV status of his transitory partner. "But what if she had HIV?!!" he'd wail. He didn't calm down until he got tested three months later and got the very predictable negative result.
posted by caporal at 9:35 AM on February 22 [1 favorite has favorites]

The Economist also covered this idea last November.
posted by rongorongo at 9:52 AM on February 22

Persuading everyone with HIV to start therapy purely for public health reasons could be ethically dubious.

WTF? I suppose persuading everyone to take smallpox vaccine was ethically dubious too, eh?
posted by five fresh fish at 10:12 AM on February 22 [1 favorite has favorites]

"If someone who is HIV positive takes antiretroviral-drug therapy they can live a long life and almost never pass on the virus, even through unprotected sex."

Where the heck did they get this idea? To my knowledge, this entire scenario is premised on false facts. Everything I have read has said that, although HIV levels in the blood may be be undetectable, there can still be detectable -- and even high -- levels of HIV in semen. Have I missed something?
posted by PigAlien at 10:23 AM on February 22

[SLNS] - Single Link New Scientist. Don your skepticism goggles and salting gloves.
posted by RockCorpse at 10:26 AM on February 22

From the article: ... scientists and policy-makers are seriously considering the concept, albeit on regional scales.

Doesn't this make it sort of pointless, if people from regions where this isn't being tried can still travel to the regions where it is?
posted by FishBike at 10:32 AM on February 22

delmoi: You mean it would take a lot of work, right when lots of people are unemployed with nothing to do.

By 'a lot of work' I mean 'for example, more work than eliminating poverty and famine from the world'. It would take more work than we've got. By a huge margin.

Hell, since this requires, as part of it, opening a stable supply line to everyone in the world, eliminating poverty and famine is actually a subset of it. Some starving subsistence farmer in Bangladesh isn't going to care about his retroviral drugs until his children are fed, and if someone wants them (say, because they want a higher dose themselves) he'll trade them away for food in a second.
posted by Mitrovarr at 10:46 AM on February 22

"Which obstacles are you referring to?"

Well, the kind of person who believes abstinence education is the right way to deal with teen pregnancy, and that AIDS is a just punishment from God for deviant sexual practice would probably find this interfering with God's virus of vengeance. I mean, surely paying government money to cure perverts for free, just so that as-yet-uninfected perverts can have deviant sex in safety, is rewarding sinful behaviour.
posted by i_am_joe's_spleen at 10:48 AM on February 22

All right! Now that we have HIV solved let's stop heart disease by making everyone eat better and exercise more.
posted by brevator at 10:50 AM on February 22 [5 favorites has favorites]

When you say "At least in theory," you can say any fucking thing you want after that.

Well, not quite. But you can say an awful lot of things, many of them foolish.
posted by fantabulous timewaster at 11:12 AM on February 22

Krrrlson: Really? We have hard numbers on this? Is there a study somewhere you could link to?
Ahmadinejad said this right after proving that Iran has no gays.

His quote was "In Iran, we don't have homosexuals like in your country," somewhat wistfully, regarding a certain lack of fabulousness of Iranian gays.
posted by Pronoiac at 4:28 PM on February 22 [1 favorite has favorites]

posted by Pronoiac His quote was "In Iran, we don't have homosexuals like in your country," somewhat wistfully, regarding a certain lack of fabulousness of Iranian gays.

Possible TV show idea: Queer Eye For The Shi'ite Guy
posted by mattdidthat at 5:24 PM on February 22 [2 favorites has favorites]

Queer Eye For The Shi'ite Guy

Off topic, but: it's been done, kinda!

Ahmed, who with two other California-based Muslim comedians forms a comedy team called Arabian Knights, described his idea for a new reality television show: "It's called 'Mideastern Eye for the Midwestern Guy.' . . . Five Arabs . . . bust into a white guy's house and teach him how to make bombs and hate women." (Pause amid laughter) "I'm kidding. Midwestern guys already know how to do that." WaPo
posted by BinGregory at 8:46 PM on February 22

Really? We have hard numbers on this? Is there a study somewhere you could link to?

The CIA world factbook has HIV stats on most of the countries in it.
posted by delmoi at 11:06 PM on February 22

And if you can't trust the CIA, why, who can you trust?

I trust the CIA Factbook
posted by five fresh fish at 11:25 PM on February 22

Re: "Ethically Dubious"

There's tons of people who don't take meds, even if it's crucial to their life. There's really only one way you can FORCE someone to take meds, several times a day. You put them in prison.

So, not ethically dubious, ethically impossible.

And then there's the fact that several populations have been subjected to forced medical procedures- whether we're talking forced sterilization, experimental vaccines with "death" as a side effect, etc. - why would they assume that this program would be different than the previous ones?
posted by yeloson at 12:21 AM on February 23

I'm not sure how this would work, given that modeling predicts that ~25% of transmission occurs during the first few weeks of infection, while folks aren't even antibody positive.

I'm certainly excited about the possibility of eliminating HIV, but this whole idea has the stink of the researcher on it. No one I know who has worked in actually providing HIV care would assume that this would work. People don't reliably and consistently take medications that alleviate symptoms, they have a hell of a time taking ARVs that don't (and that actually make them feel worse). Even when the meds have brought someone back from near-death, once folks start feeling good again it's hard for many to stay focused. Even testing is problematic: I work in an area that CDC categorizes as high risk (>1% prevalence), testing is easy and free, and people still avoid it.

And the whole way society treats AIDS victims would have to be different. If you categorized AIDS suffers into two categories:

1. angelic AIDS victims who are receiving steady treatment and are suffering for the good of society.
2. demonic AIDS criminals who shirk treatment and put all of humanity at risk.

We already do this. The trouble is that the demonic folks, understandably, want to stay under the radar. It's a disaster from a public health point of view. It's great for moralistic self-righteousness, not so good for actually making a positive difference.
posted by OmieWise at 4:39 AM on February 23

1. angelic AIDS victims who are receiving steady treatment and are suffering for the good of society.
2. demonic AIDS criminals who shirk treatment and put all of humanity at risk.

Actually, the way AIDS sufferers get divided up is as follows:

1. angelic AIDS victims who catch it through no fault of their own, like a blood transfusion
2. demonic AIDS criminals who contract it through drug abuse or homosexual acts.
posted by dunkadunc at 5:37 AM on February 23

All I can say is smallpox. Humanity could use some more grand projects. We need to be reminded we can do this stuff.
posted by saysthis at 7:59 AM on February 24

The issues are radically different. Getting everyone vaccinated and making sure everyone takes their medication exactly the right way, side effects, social and political situations be damned, every day for the rest of their lives, are so radically different as to obviate the comparison. Just because it's two diseases under consideration isn't enough to sustain it.
posted by OmieWise at 1:46 PM on February 24

Moon landings, too, saysthis. Been way too long since we showed we could do it.
posted by five fresh fish at 5:03 PM on February 24

U.S. Stand Jeopardizes Global Anti-HIV Push
posted by homunculus at 9:25 AM on March 7