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.]