The end of AIDS?

PrEP for African schoolgirls? Have we lost our minds?

The following article appeared in The Economist on September 17, 2023. It’s just about what you’d expect, and includes some predictable bashing of former South African President Thabo Mbeki, but there are a few curiosities I’d like to bring to light.

The end of AIDS is in sight

From the beginning, there is no attempt to hide their agenda, which is to get as many people as possible on a lifetime of ARVs, with a particular push for PrEP for HIV-negatives. In all cases, emphasis is added by me.

Many people who do not have HIV, the virus that causes AIDS, know they are at risk. They can take pre-exposure prophylaxis (PrEP), a kind of drug that reduces their chance of contracting it by 99% or so. This comes as a daily pill, and is popular among gay men in rich countries.

However, there is a much larger group of people at high risk, for whom a daily pill is far from ideal: heterosexual women in poor places where HIV is still very common. If their boyfriends discover they are taking the pill, they may conclude that their girlfriend does not trust them, or that she is planning to cheat on them. And a depressing number of boyfriends who suspect such things react violently.

There appears to be an agenda to “save PEPFAR at all costs,” despite the controversy surrounding the program.

Unfortunately, triumph has bred complacency, argues Peter Sands, the head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, a donor-financed body. “There’s a diminishing sense of urgency,” he says. Or worse. The biggest donor by far is America. Its global AIDS programme, PEPFAR, which was set up by President George W. Bush, expires on September 30th and some Republicans are trying to block its reauthorisation. A recent report from a conservative think-tank called aids “primarily a lifestyle disease” and griped that PEPFAR was being used to promote a “radical social agenda overseas”. (It does not bar aid recipients from talking about abortion.) Mr Bush is horrified. “To abandon our commitment now would forfeit two decades of unimaginable progress and raise further questions about the worth of America’s word,” he fumed in the Washington Post on September 13th.

(Mr. Bush is horrified! No comment.)

There is also aggressive promotion of the “95-95-95” framework, which would result in fully 86% of HIV positives worldwide being “retained in care” on antiretroviral drugs. There appears to be no specific target listed for what proportion of “risk group” populations “need” to be on PrEP, according to UNAIDS. I’d be very interested in seeing that figure.

There is also the predictable creepy push to test and drug as many pregnant women as possible. Will they be offering them PrEP as well at prenatal clinics? What could possibly go wrong?

UNAIDS urges countries to aim for “95-95-95”: where 95% of those who have the virus know they have it, 95% of those who know they have it are receiving treatment, and crucially that 95% of those in treatment are “virally suppressed”. If the drugs suppress the virus to a level where it is undetectable—and keep it there—it cannot be passed on sexually.

If the world were to reach 95-95-95, the disease would be brought under control, unaids reckons, though tens of millions would still be living with it. In 2022 the figures were 86-76-71, a hefty improvement on 71-48-40 in 2015. But the “last mile” will be hard. “You have to be much more creative,” says Dr Quarraisha Abdool Karim of caprisa, a research centre in Durban.

One enormous, tricky group is men. They are less likely to get tested than women, not least because they do not get pregnant. Prenatal clinics are a wonderfully convenient place to test women who have recently had unprotected sex. If they test positive, many countries now offer them free drugs, which protect mother, child and future romantic partners.

Here we go, targeting Black women and their babies for PrEP, because—among other reasons—they might get infected by their “sugar daddies.”

Do these people not know that the “sugar baby” phenomenon is also common in western countries? It’s interesting to me that the best explanation the HIV AIDS dogmatists give for why HIV AIDS is mainly a heterosexual disease in Africa is that their “dominant strain” of HIV is spread “primarily through vaginal sex” whereas that is not the case for the “Western strain,” which is allegedly more easily transmitted via anal sex. (From Denying AIDS by Seth Kalichman, but is referenced many places.) This is completely nonsensical because it necessarily assumes that for the last forty years there has been no mixing or international travel that should logically result in both strains existing in both areas. The official story does not depict the behavior of any infectious agent. (It’s also nonsensical because there are multiple “strains of HIV,” to the point that no two identical strains have been isolated even from the same patient.)

It is, perhaps, most crucial to reach young women and girls. In sub-Saharan Africa hivis three times more common among females aged 15-24 than among their male peers. This is because older men often seek younger partners. There is peer pressure on young women to have trendy clothes and hairstyles, says Ms Tshabalala. These cost money, which impels some girls to sleep with older men. And only 36% of young women in eastern and southern Africa report having used a condom the last time they had sex with a casual partner. In West Africa it is only 25%.

If their “sugar daddies” infect them, the girls may pass the virus to a partner of their own age. This is the most common way that HIV passes from one age cohort to the next. Breaking that link would allow the younger cohort, who are largely virus-free before they become sexually active, to stay that way. “If you can reduce [new infections among] young girls, you break the back of the pandemic in Africa,” says Dr Salim Abdool Karim, an epidemiologist (who is married to Quarraisha Abdool Karim).

The primary reason I wanted to cover this piece is to highlight the “solutions” that have been suggested by researchers. The first involves a bimonthly PrEP injection. We’ve seen this before; we’ve also seen other long lasting solutions such as subdermal implants. Given the problems that many women have experienced due to long-acting shots or implants for birth control, this may not be that promising if their goal is “adherence.” It’s lucky for the drug manufacturers that these poorer countries don’t tend to have very litigious citizens, because if they did I imagine we’d see class action lawsuits that make the Truvada disaster look like a joke. We may yet see them.

A high-tech solution is on the horizon: cabotegravir, from ViiV healthcare, a single injection that lasts for two months and is much more discreet than a daily pill. Alas, it is new, costly and not yet widely available, especially in Africa, where the virus is most widespread. So Patrick Mdletshe of the KwaZulu Natal Provincial Council on aids in South Africa offers a low-tech fix: stuff cotton wool in the bottle so the daily pills don’t rattle and your boyfriend won’t notice that you are taking them.

I’ve saved the really shocking part for the end. Having weighed various “solutions” to the problem of “young women getting infected by their abusive sugar daddies,” they settle on the following: going into schools and offering PrEP to girls—children.

Governments do not work in a vacuum. The places that have come closest to hitting the 95-95-95 targets are typically African countries where donors are pouring in resources and expertise, such as Botswana, Rwanda, Tanzania and Zimbabwe. The second tier are often rich countries with generous public services (Denmark, Saudi Arabia) or places that developed a serious anti-AIDS strategy early on in the pandemic, such as Cambodia and Thailand.

One of the biggest obstacles to curbing the spread of HIV is that the symptoms take a long time to appear. “Recently infected people have high viral loads, and are more likely to infect others. The problem is that those who have been infected don’t yet know it,” laments Dr Salim Abdool Karim. “The gap between being infected and being tested is usually years.”

So he suggests something radical: offering PrEP to girls in schools. Instead of waiting for those who think they are at risk to come to a clinic, health workers should go to schools and offer PrEP to all the girls above a certain age, along with testing, contraception and other healthcare services. This could meet stiff resistance from traditionalists who think it would encourage promiscuity. Also, “[it] is only feasible if you have a PrEP that lasts six months,” says Dr Salim Abdool Karim. “You can’t keep going to the schools more than…once every six months. It’s not practical.”

I’m not especially concerned about “encouraging promiscuity” among schoolgirls. Those of us who are parents to teenagers—heck, those of us who once were teenagers—know that adult intervention isn’t going to stop teenagers from fooling around, in any country. This isn’t unique to African countries. The implied and overt racist stereotypes about African sexual behavior are truly nauseating.

What does concern me is the push to start as many people on PrEP as possible, as young as possible, preferably before the age of majority. No one knows what the effects of being on these drugs for a lifetime will be, but current indications should serve as a warning that they won’t be good for much other than lining the pockets of the pharmaceutical company executives. The entire PEPFAR scheme, as well as the push to get everyone in a “risk group” on PrEP, although the definition of “risk group” seems rather fluid as well, smacks a little bit of colonialism and a lot of greed on the parts of everyone pushing this shameful concept.

As always, let me know in the comments what you think of these developments, especially the “novel approach” of offering PrEP to teenage girls.

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