HIV Vaccine: Bad News?
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Is the development of a partially effective HIV vaccine actually bad news for public health?
In the long term, the answer would seem, of course, to be: no. Progress toward an effective HIV vaccine after so many years of failure has to be good news.
But, in the short term, the picture is not nearly so clear. This article from the Times Online lays out the case:
With most infectious diseases, reducing everyone’s risk by a third would make quite a difference across a whole population. But the problem with HIV is that it is both an infectious disease and a behavioural one. I can get it by sharing needles with other drug injectors, I can avoid it by using condoms every time I have sex. If I know I have been vaccinated, will that make me more likely to share needles, or less likely to use condoms? And if it does, will that change outweigh the 30 per cent reduction in risk that comes with the vaccine?
The problem is what’s called “behavioral disinhibition” — that is, if you think you’re protected from AIDS, maybe you don’t think you have to be so careful anymore. And that sudden lack of care can swamp the public-health gains from the thing that made you feel protected in the first place.
It’s not an entirely theoretical problem, as the Times Online article explains:
We do know that after HIV treatment became universally available in this country, condom use in the gay community fell and new HIV infections rose, even though treatment greatly reduces the risk of passing the virus on. Could the same thing happen if people feel protected by a vaccine? Probably.
A similar natural experiment is underway in Africa, where the first large-scale circumcision programs are underway to combat AIDS on the continent. (Circumcision has been shown to reduce the chance of getting AIDS through heterosexual sex by up to 60%; but will behavioral disinhibition overwhelm the benefits?)
I don’t think this backfire effect should be enough to prevent an HIV vaccine from becoming available — especially for populations that aren’t engaging in safe behavior in the first place. But it’s sure to be an issue of hot debate in the public-health community.
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I’m not sure that there will be debate on this issue hot or otherwise. Since it’s unlikely that anyone is going to advocate people stop practicing safe sex due to a partially effective vaccine being discovered where exactly do you expect this hot debate to be going on?
Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are more likely to be HIV+ if they’ve been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms.
The one study into male-to-female transmission showed a 50% higher rate in the group where the men had been circumcised btw.
ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
This is a great example of the “sacrifice trap.”
http://www.overcomingbias.com/2009/09/the-sacrifice-trap.html