November 07, 2007

Slow Trot for the Cure

Will anyone ever develop an AIDS vaccine? On some level, it looks doubtful (not least because the virus mutates so quickly), and yet a sizeable chunk of the world's $10 billion in AIDS spending each year goes to finding a cure. Increasingly, though, scientists and doctors are saying we should put less hope in a technological fix and spend more of that money on proven, low-tech strategies like circumcision, sexual monogamy, and birth control. Also, the vaccine trials are becoming horrifying:
Among a group of nearly 700 subjects worldwide who received two doses of the vaccine, 19 became infected with HIV, compared with 11 for a similarly sized group that received placebos. The finding alarmed some scientists and underscored the tricky ethics of using human subjects to test potential remedies for incurable diseases.

South African researchers last week began warning hundreds of volunteer test subjects that the vaccine might actually have increased their risk of contracting HIV.

Two trials for microbicides—gels that women insert into their vaginas to prevent infections—also ended when more women using the experimental substance became infected with HIV than those using placebos. Scientists theorize that vaginal irritation caused by these products may have made it easier, not harder, for the virus to infect women. A study of whether diaphragms might inhibit HIV found that they were also ineffective.

"It's been an appalling year for the biologists," said Francois Venter, president of the Southern African HIV Clinicians Society.
Then again, as William Easterly explained in his review of Helen Epstein's new book, The Invisible Cure, Western aid organizations haven't exactly done a bang-up job of promoting "proven, low-tech strategies," either. Uganda had great success with its ABC strategy—"Abstain, Be Faithful, and Use Condoms"—but religious groups loathed the condom part of that campaign, and NGOs were lukewarm about the "Be Faithful" aspect. (After all, family-planning groups are happy to flood African countries with condoms—an activity that attracts donors and aid money—but there's no large bureaucracy supporting a "Zero Grazing" campaign.)

Easterly jokes, bleakly, that most NGOs have their own ABC strategy—antiretroviral drugs, bureaucracy, and consultants. Most AIDS money gets spent on treatment rather than prevention (although the Bush administration has lavished tidy sums on useless abstinence campaigns). One U.S. ambassador to South Africa recently told groups receiving AIDS funding that they should cut back on prevention rather than treatment during budget crunches, noting: "Our priority must be delivery of treatment services." Only problem: ARVs are expensive, not nearly as cost-effective as prevention, and will never be able to reach everyone.

Now, I'm generally not as sour as Easterly about foreign aid, but he makes a solid case here. He's especially scathing toward Western consultants who swoop in to implement their own AIDS programs, but ignore homegrown efforts (as when a Christian group, Hope Worldwide, came into South Africa to do work with AIDS orphans but utterly neglected an already existing, and mildly successful, orphanage). That's Epstein's message, too: "[O]ur greatest mistake may have been to overlook the fact that, in spite of everything, African people often know best how to solve their own problems." It's a point worth heeding, especially since AIDS funding is exploding, and the potential to compound past mistakes seems very, very large.

P.S. By the way, Epstein's advice sounds sturdy, but it's also different from saying that all countries can take care of themselves. For instance, this recent paper by Evan Lieberman found that countries that are ethnically divided and fragmented (as many African countries are) are far, far less likely to pursue aggressive AIDS policies, for a variety of reasons—various ethnic groups are more likely to fear stigmatization; elites are more likely to blame only certain groups, or downplay the threat, and so on.
-- Brad Plumer 11:41 AM || ||