No more magic bullets

So I went to the Lancet session on prevention, and what a change from two years ago!

In Toronto 2006 the big buzz of the conference was prevention, but a specific kind of prevention, namely the New Prevention Technologies (NPTs). Oh yes! Bills Gates and Clinton were in full agreement. Let's pour shedloads of money into microbicide research and vaccines and, though it's a ‘challenge' because you always have to say that, one day we'll have a nice easy to use prevention method that will mean everyone's protected, or at least more than they are by Condoms and Being Faithful.

This year? Every single speaker, and we're talking about people like Peter Piot of UNAIDS and Tom Coates, one of the foremost NPT proponents in the world, stressed that there was "no magic bullet". HIV prevention had to be and would always have to be a combination phenomenon.

And that doesn't mean using a microbicide AND a condom. No, it means attacking people's vulnerability to HIV at EVERY level: researching new prevention methods, yes, sure (and I'm still a vocal campaigner for microbicides and oral PreP), but also:

- Doing the simple stuff we already know (condoms, lube, needles) with the right people at the right time and not handing out condoms to people who aren't in any danger of HIV or refusing needle exchange because national governments are too hostile or embarrassed to sanction programmes for fags, whores, and junkies (and I've been two out of those three).

- Asking people how they'd like to change their behavior and devising supportive methods to help them make that choice.

- Instituting adequate surveillance and testing programmes so we know who has HIV, who's catching it and how that's changing. Otherwise we're working in the dark. That's epidemiology; it sounds dry, but what it means in practice is, for instance, standing in a park in Mombasa at midnight interviewing a group of rent boys whose existence we were unaware of till a few years ago - and making sure you and they don't get beaten up by the police in the name of science.

- Asking people what they'd like to change about their environment (i.e. the stuff they can't change) and then mobilizing structural interventions to change it. That means anything from anti-domestic-violence campaigns to microcredit unions to changing laws that criminalise drug users and gay men and HIV transmission.

- And you have to do it ALL, without skimping on any component, and you have to do it EFFICIENTLY. Stefano Bertozzi of the US NIH showed a wonderful slide that showed that the cost of testing a single new person for HIV in different projects varied from $1 to $1000. Some countries as time went along managed to achieve efficiencies of scale, like India, and testing got cheaper. Some like Russia and I regret to say Mexico were still spending $1 per test on some centres and $1000 in another. Or rather on the director's Mercedes, I imagine.

So why won't a magic bullet ever, ever, ever work? (Well: possibly, possibly, when we eventually get that cheap, one-shot, 100% effective, cheap, sterilizing immunity vaccine. But not till then. Don't hold your breath).

Because of human nature, that's why. People don't act rationally around sex or drugs and they do what they do for a mix of countless different motives. And this is what the NPT researchers have been encountering, recently, in a way that would be comic if it weren't tragic.

One thing they found is that people lie about sex. Not a little bit. Bigtime. And especially to researchers. They lie so much you have to take every single behavioural survey of sex risk with a big pinch of salt. At the end of last year the failure of the microbicide Carraguard was announced. It probably failed, not because it didn't work, (it might have done, a bit, we'll never know) but because the women volunteers who had to use the stuff said they used it 19 times in every 20 they had sex but actually only used it about half the time.

Another thing they've found out is that people don't even know what researchers are talking about. There was a comical moment in a session on circumcision yesterday when Bertran Auvert, the decidedly gung-ho French researcher who put on the first successful trial of circumcision to prevent HIV in Orange Farm, South Africa, gave the results of a survey on whether men in the same area as the trial would be willing to be circumcised and whether circumcision affected sex pleasure.

They found out that a quarter of the men in Orange Farm were already circumcised.

Oh no they didn't. Because when they actually asked more carefully - and that meant researchers carrying around with them large, laminated photos of circumcised and uncircumcised dicks, such are the things researchers have to do - they found that nearly half the men who thought they were circumcised...actually weren't. They thought ‘circumcision' meant you'd been through some kind of tribal initiation ceremony. No one had previously thought to check that people understood what the word meant. One young guy, shown a photo of a cut dick, was reportedly ‘astounded'. I bet he was.

The serious aspect of this was that the offer of free circumcision was dependent on self-reported circumcision - so a lot of guys missed out.

They also found that the guys who'd been circumcised said it improved their enjoyment of sex....as did the guys who thought they'd been circumcised but hadn't. Which means, once again, that what the guys were doing was not telling the truth, but telling the researchers what they thought they'd want to hear.

I zoom in on these two examples simply as illustrations of the kind of complexity prevention researchers battle with. And these are simple examples. What about the effort of putting on a circumcision programme in a country where one particular tribal group's sense of identity is partly based on the fact that they're the ones with foreskins?

Tom Coates ended his presentation by saying that HIV was ‘about changing human behavior - not incrementally, but radically'. He meant that tinkering at the edges won't work. You have to be bold enough to presume that you can change the way an entire nation or population does sex.

Impossible? Well, 12 years ago I typed my first-ever Word document and looked up my first-ever internet web page. These days I can't imagine my existence without Facebook and blogging and Google. If I hadn't changed my behaviour I'd still be writing this on an Olivetti and duplicating it on a Gestetner. People will change their behaviour utterly if there's an incentive. Finding the right incentive is finding the true magic bullet.