HIV prevention not working, leading HIV doctors warn

Preventive measures are failing to curb the rise in HIV infections, according to an editorial by two leading British HIV doctors in the 12^th February edition of The British Medical Journal.

According to current estimates, 38 million people are now living with HIV worldwide, including 2 million children. In 2003, a record 4.8 million people became infected with the virus.

Angela Robinson from University College London Hospital and Brian Gazzard from London’s Chelsea and Westminster Hospital, argue that the underlying reason for the continued increase is socioeconomic. “HIV infection is rooted in poverty, ignorance and a lack of autonomy of women,” they state.

However, they also state that current prevention measures are failing to stop the rise in new infections.

While an effective HIV vaccine would be the ideal prevention measure, trials so far have been disappointing. “Hopes for an early breakthrough are not high,” they warn.

Similarly, the development of microbicides to prevent transmission of HIV has been dogged by difficulty. This includes trials of nonoxynol-9, which was found to damage the lining of the vagina and have no protective effect on HIV transmission.

Although several alternatives are in the pipeline, lengthy trials are required to test their effectiveness.

“Other preventive measures include the administration of single antiretroviral agent as pre-exposure prophylaxis in risky sexual encounters, but generating resistant virus is a serious concern,” they warn. “For the present, most efforts at prevention are therefore linked to trying to change behaviour.”

The doctors cite Thailand and Uganda as areas where attempts at changing behaviour have co-incided with falls in the incidence of new HIV infections. However, they warn that this does not prove a causal link, and may be a “natural consequence of the changing epidemic.”

They also warn that the “ABC” message that is popular with the American government – abstinence, be faithful, use condoms – may not be effective in other parts of the world. “A range of approaches are [sic] needed tailored to the drivers of the epidemic.”

On a more positive note, the authors point out that the use of antiretroviral drugs in resource-limited settings has increased following a reduction in cost because of “generic manufacture and political pressure applied to the pharmaceutical companies.” The high rates of adherence and low toxicity has provided hope to infected people in these areas, as well as increasing HIV testing, which may reduce the rate of HIV transmission.

Although the epidemic in the United Kingdom is small in comparison to the global catastrophe, there was a 20% increase in the prevalence of HIV in this country in 2003 and 2004 compared to 2002. This, they warn, included a doubling of the risk of heterosexual transmission.

“Each newly diagnosed HIV patient consumes about £12,500 in healthcare costs each year,” they estimate. “The lifetime costs of care for the current 50,000 infected individuals in the United Kingdom…is [sic] at least £12.5bn.

“Prioritisation of sexual health with substantial investment is essential to avoid continuing deterioration in services, rising HIV transmission, and costly consequences for tax payers.”