Tuesday, August 22, 2006

Impressions of the XVI International AIDS Conference in Toronto

What was hot at the recent International AIDS Conference in Toronto? Answer: new developments in HIV prevention research and policy. Kevin de Cock, the new HIV/AIDS director at WHO, seemed to have summarized the zeitgeist by stating that 'We cannot treat our way out of this epidemic', and hence that halting new HIV infections should be considered the main priority. At the 2004 conference in Bangkok, the conference theme was 'Access for all', a reference to initiatives to get anti-retroviral treatment to needy HIV positive patients worldwide. Now the pendulum of attention seems to have swung somewhat from ensuring treatment of HIV infected persons to preventing people getting infected in the first place. This shift is not surprising, if you think about it: 25 years into the epidemic, there is still no vaccine, still no cure, and the effectiveness of the conventional ('ABC') means to prevent HIV infection seem pretty limited considering that more new HIV infections occurred in 2004 than any previous year of the epidemic. Something has to be done to stem the tide, because, frankly, the virus is winning and we are losing.

What's big in HIV prevention research? Answer: microbicides and male circumcision. The advantage of microbicides is that they are 'female-controlled' prevention methods, which could circumvent the problems associated with negotiating condom use with men. Some of the bigger names (like Melinda Gates, wife of Bill) used microbicide research as a springboard for the idea of 'putting the power in the hands of women' to change the course of the epidemic, but this girl power ideology was soon derided by some public health experts ('Aren't men involved in there somewhere?') and swiftly criticized as inappropriate by gay men's groups.

As far as male circumcision goes, there was not much new data to report, but some cost-effectiveness and epidemiological modeling talks based on a recent South African study strongly suggested that the implementation of male circumcision among non-circumcising groups in sub-Saharan Africa would be economically feasible and have a significant impact on HIV prevalence in Africa over the next twenty years. Interestingly, there was no one on the panel in the session on circumcision from the social sciences or African civil society, and therefore little discussion about the possible political and cultural challenges faced by the initiation of male circumcision into non-circumcising communities in Africa. Many in the audience, however, seemed deeply uncomfortable about the idea of (mostly white people and Western institutions) going in and circumcising African males, no matter what the data currently indicated, unless there was a better understanding of what reforming old and introducing new circumcision practices could entail for local communities.

One surprise was the open criticism of recent policy initatives to accelerate HIV testing. While it makes good sense to explore ways of increasing knowledge of HIV status (around 90% of those HIV infected in sub-Saharan Africa do not know their status), there was much debate about the human costs of policies of 'routine HIV testing' in clinical settings: problems with informed consent, the lack of emphasis on counseling, potential exposure to stigma and the fragile links between testing positive for HIV and having access to AIDS treatment. Amnesty International just weighed in on the issue. The epidemic, and its ethical debates, rage on.


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