Notebook: What happens when we realize a vaccine isn't possible?

The HIV/AIDS research community has finally come to the conclusion that a vaccine will likely never come. More than one expert has said this in the last year. A few elder statesmen of long experience in the infectious disease research community have come out and said that HIV/AIDS is a disease easily avoided with a long period of incubation, usually past the years of child-bearing and most of those of child-rearing, that in most countries affects a small number of people engaging in very specific contagious behavior. Nature and evolution simply do not find this disease to be a major problem. Hence, it is less a threat to world humanity than a personal tragedy to individuals and those countries hardest hit.

We have entered a new period in the development of the HIV/AIDS era. The emphasis will now be on prevention. The HIV/AIDS research world is awash in money. If the donor community accepts that a vaccine is not possible, billions of dollars will flow elsewhere. Economics dictates that the recipients of donor largesse will have to shift their research and activities to continue receiving these huge sums of money, recipients being institutions rather then individuals. Hence, we saw the World Health Organization endorse male circumcision. Then we saw the United Nations add their voice as well.

More than a few people were perplexed at the apparently bizarre interest the vaccine activist community  had in male circumcision. The AIDS Vaccine Advocacy Coalition and the International AIDS Vaccine Initiative both became positively giddy at the prospect of male circumcision. I now question whether they have concluded privately that the vaccine effort's days are numbered. Closer than anyone to the effort and more dependent on donors than even the research institutions, which usually have more than one focus, they perhaps see an opportunity for continued viability in the promotion of genital surgeries.

The evidence for male circumcision is weak. Its efficacy in a clinical setting is unclear. Its effectiveness in the general population is negligible. No one seems ready to acknowledge that all the players in the male circumcision push have vested interests. Yet, the United States Centers for Disease Control (CDC) appears ready to endorse it, falling in line with the United Nations and the World Health Organization. Given the condescending attitude of most US government institutions, I suspect the CDC is more than a little annoyed that they were beaten to the punch.

The CDC condemned the new Swiss guidelines on HIV+ infectiousness almost immediately. More than eight years of evidence went into the formulation of the new guideline. In prevention terms, why support male circumcision so quickly and condemn the proven prevention value of ARV therapy? The CDC will eventually come around to support the Swiss viewpoint. Right now, the new guidelines are an uncomfortable, counterintuitive change in direction. But it is fundamentally a technical question of prevention. Male circumcision on the other hand is an American cultural norm that evokes a fierce commitment to its continued practice in the United States. However, it is new to the HIV/AIDS scene. Hence it has attracted interest as it involves the creation or expansion of new organizational structures and materials, and provides a new opportunity for advocacy and the allocation of resources.

So where is the world now viz HIV/AIDS and male circumcision?

If the experts have concluded both that a vaccine is not possible and that HIV is little more than a personal tragedy for individuals in the developed world, I think we can expect a mad scramble for prevention funds. This will likely involve all sorts of new and innovative efforts, of which more than a few will involve genital mutilation. We can likely look forward to continued forced circumcisions of children and scaremongering to induce submission in adults. Much like the early period of HIV/AIDS, ethics and human rights will take a hit.

[This article has been reprinted as a news item on the European AIDS Treatment Group website.]

Comments

[Alastair Jenkins]

This post appears to me rather defeatist. Certainly the recent anti-MGM moves in Australia, and continuing anti-MGM feeling in Canada give us cause for hope. In the rest of the non-MGM world there is almost complete ignorance and apathy on the subject ("it couldn't happen here", "only for Muslims and Jews", etc.), except for some pseudoscientific opportunists. Mutilation appears unlikely to spread to non-mutilating populations outside Africa.

[David]

Thanks for the comment. Perhaps I am being defeatist. I remain hopeful in spite of it all.

[Joe]

I agree with Alastair especially with respect to the recent anti-MGM moves that have occurred in Australia and Canada the issue isn't getting anywhere near the attention it has here, curious. As an example I was recently reading the RACP policy statement after reading a separate news article about it and with regard to this issue they state in part: "However, how much circumcision could contribute to ameliorate the current epidemic of HIV is uncertain. Whatever the future direction of this debate it can not be seen as an argument in favour of universal neonatal circumcision in countries with a low prevalence of HIV." This gives me hope; it tells me that there are men and women with excellent ethical character within those organizations. They are from a country that recently pulled themselves from this atrocity and, looking ahead, preemptively said what ever happens this will be an adult decision, as it should be.

And that is really the thing that amazes me the most. Why is it so hard to simply approach it from this angle? By deferring this and letting each man choose you completely eliminate the ethical questions. Those who want it get those who don't won't; everyone is happy and it makes everything easy. Here in the US though it seems like we always have to do things the hard way. And perhaps the reason is that most rational people, when presented with such an option, will not take it. Why? because it in no way changes my responsibilities; that's why. So it comes down to whether or not doctors intend to be ethical. To this point US doctors have been very unethical with respect to MGM though I think things are slowly improving. The formally cutting Australians made the leap we can too. All that we have to do is put common sense and ethics up front where they belong.

With respect to the assertions there may never be a vaccine I think that is bull. Nothing is impossible; a cure just might not take the form of a typical vaccine. It could be like your post in June. Or the
December post boy those Germans are on the ball. So there will be a cure; the important thing is to continue the search.

[Hugh]

I hope you are wrong that there will never be a vaccine. The virus may seem tricky (it evolves fast) but humans are intelligent. New approaches are always being tried. (Even if we don't find one, the function for the virus of defeating our immune system is not to kill us but to protect itself, and killing us never benefits and always harms the virus, so eventually it will evolve into a variety that doesn't do that. That is the natural progression of new plagues.)

The other virus that we need to worry about is the circumcision memeplex, a virus of the mind. See http://www.circumstitions.com/meme.html People seem to have no natural immunity to this virus. The vaccine is simple, just coherent thought and access to the facts. People need to escape from the mindset that cutting part of babies' genitals off is "normal" "usual" and "heath-promoting" - a mindset that pervades the discussion of circumcision to prevent HIV.

[Joe in Ca]

"People need to escape from the mindset that cutting part of babies' genitals off is "normal" "usual" and "heath-promoting" - a mindset that pervades the discussion of circumcision to prevent HIV. "

I find it interesting how advocates of infant circumcision are quick to forget that circumcision is an artificial, FORCED phenomena.

To call the arranged, modified penis "normal" and/or "natural" is somehting of a paradox, isn't it.

[Michael Petrelis]

david,

i love your outlook on these issues. as you know, i am working to bring debate to the swiss report, which should really be leading us to actively promoting PEP and PREP.

i believe here in SF the DPH and AIDS Inc, if they were really interested in halting HIV, would educate sexually active, and drug-using, gays to learn about PEP and PREP.

if i had the money and time, i'd organize a guerrilla campaign informing folks about medicating with AIDS drugs before sex, when a man knows he will be having sex without condoms and with mixed status partners. that is pre-exposure preparation.

and also educate about keeping some PIs around the medicine cabinet for when you slip up, and may have or know you've been exposed to HIV. this is post-exposure prophylaxis.

DPH and AIDS inc know the drugs could help reduce the 1000 annual new infections, but that would require abandoning old, ineffective thinking.

lastly, i'm working with a small global network on an open letter , calling for more debate on the swiss report.

david, i hope you'll sign it. i'll send a copy of the draft, once i have it.

michael

[Scott]

I agree that with time a vaccine will be discovered - what is worrisome is the possiblity that the mutilators will have made the meme of circumcision spread more widely in the meantime, making the task of eliminating this barbaric practice that much harder. Hopefully, that won't happen. I am also concerned (frequently, when discussing circumcision) with the common practice of excusing religious groups from their moral culpability in mutilating their children. My family is Jewish, but I deserve protection too. Except in rare circumstances, all neonatal circumcision is a crime, no matter the "medical" or religious excuse.