http://www.economist.com/node/18774722
Thirty years of a disease
The end of AIDS?
Thirty years on, it looks as though the plague can now be beaten, if the world has the will to do so
Jun 2nd 2011 | from the print edition
ON JUNE 5th 1981 America’s Centres for Disease Control and Prevention
reported the outbreak of an unusual form of pneumonia in Los Angeles.
When, a few weeks later, its scientists noticed a similar cluster of a
rare cancer called Kaposi’s sarcoma in San Francisco, they suspected
that something strange and serious was afoot. That something was AIDS.
Since then, 25m people have died from AIDS and another 34m are
infected. The 30th anniversary of the disease’s discovery has been taken
by many as an occasion for hand-wringing. Yet the war on AIDS is going
far better than anyone dared hope. A decade ago, half of the people in
several southern African countries were expected to die of AIDS. Now,
the death rate is dropping. In 2005 the disease killed 2.1m people. In
2009, the most recent year for which data are available, the number was
1.8m. Some 5m lives have already been saved by drug treatment. In 33 of
the worst-affected countries the rate of new infections is down by 25%
or more from its peak.
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Even more hopeful is a recent study which suggests that the drugs used to treat AIDS may also stop its transmission (see
article).
If that proves true, the drugs could achieve much of what a vaccine
would. The question for the world will no longer be whether it can wipe
out the plague, but whether it is prepared to pay the price.
The appliance of science
If AIDS is defeated, it will be thanks to an alliance of science,
activism and altruism. The science has come from the world’s
pharmaceutical companies, which leapt on the problem. In 1996 a batch of
similar drugs, all of them inhibiting the activity of one of the AIDS
virus’s crucial enzymes, appeared almost simultaneously. The effect was
miraculous, if you (or your government) could afford the $15,000 a year
that those drugs cost when they first came on the market.
Much of the activism came from rich-world gays. Having badgered drug
companies into creating the new medicines, the activists bullied them
into dropping the price. That would have happened anyway, but activism
made it happen faster.
The altruism was aroused as it became clear by the mid-1990s that
AIDS was not just a rich-world disease. Three-quarters of those affected
were—and still are—in Africa. Unlike most infections, which strike
children and the elderly, AIDS hits the most productive members of
society: businessmen, civil servants, engineers, teachers, doctors,
nurses. Thanks to an enormous effort by Western philanthropists and some
politicians (this is one area where even the left should give credit to
George Bush junior), a series of programmes has brought drugs to those
infected.
The result is patchy. Not enough people—some 6.6m of the 16m who
would most quickly benefit—are getting the drugs. And the pills are not a
cure. Stop taking them, and the virus bounces back. But it is a huge
step forward from ten years ago.
What can science offer now? A few people’s immune systems control the
disease naturally (which suggests a vaccine might be possible) and
antibodies have been discovered that neutralise the virus (and might
thus form the basis of AIDS-clearing drugs). But a cure still seems a
long way off. Prevention is, for the moment, the better bet.
There are various ways to stop people getting the disease in the
first place. Nagging them to use condoms and to sleep around less does
have some effect. Circumcision helps to protect men. A vaginal
microbicide (none exists, but at least one trial has gone well) could
protect women. The new hope centres on the idea of combining treatment
with prevention.
A question of money
In the early days scientists were often attacked by activists for
being more concerned with trying to prevent the epidemic spreading than
treating the affected. Now it seems that treatment and prevention will
come in the same pill. If you can stop the virus reproducing in
someone’s body, you not only save his life, you also reduce the number
of viruses for him to pass on. Get enough people on drugs and it would
be like vaccinating them: the chain of transmission would be broken.
That is a huge task. It is not just a matter of bringing in those who
should already be on the drugs (the 16m who show symptoms or whose
immune systems are critically weak). To prevent transmission, treatment
would in theory need to be expanded to all the 34m people infected with
the disease. That would mean more effective screening (which is planned
already), and also a willingness by those without the symptoms to be
treated. That willingness might be there, though, if it would protect
people’s uninfected lovers.
Such a programme would take years and also cost a lot of money. About
$16 billion a year is spent on AIDS in poor and middle-income
countries. Half is generated locally and half is foreign aid. A report
in this week’s
Lancet suggests a carefully crafted mixture of
approaches that does not involve treating all those without symptoms
would bring great benefit for not much more than this—a peak of $22
billion in 2015, and a fall thereafter. Moreover, most of the extra
spending would be offset by savings on the treatment of those who would
have been infected, but were not—some 12m people, if the boffins have
done their sums right. At $500 per person per year, the benefits would
far outweigh the costs in purely economic terms; though donors will need
to compare the gain from spending more on knocking out AIDS against
other worthy causes, such as eliminating malaria (see
article).
For the moment, the struggle is to stop some rich countries giving
less. The Netherlands and Spain are cutting their contributions to the
Global Fund, one of the two main distributors of the life-saving drugs
(the other is Mr Bush’s brainchild, PEPFAR), and Italy has stopped
paying altogether.
On June 8th the United Nations meets to discuss what to do next.
Those who see the UN as a mere talking-shop should remember that its
first meeting on AIDS launched the Global Fund. It is still a long haul.
But AIDS can be beaten. A plague that 30 years ago was blamed on man’s
iniquity has ended up showing him in a better, more inventive and
generous light.
