Question: Why have HIV prevention efforts failed to curb the spread of the pandemic?
Answer: Prevention has failed for many reasons. One is that we didn't actually start prevention until we had reached such a critical mass of HIV infection that prevention was always going to be difficult. The higher the prevalence in the population, the more effective prevention needs to be just to keep levels constant, let alone lower prevalence.
Globally, we missed some really easy wins when it comes to HIV prevention. One was needle exchange programmes for injecting drug users. Countries which have adopted these policies and adjusted their laws to accommodate them have virtually wiped out HIV among these populations. Unfortunately, a lot of countries have chosen not to do that, including the US and Russia.
Another easy win is providing commercial sex workers with condoms, lubricant and sexually transmitted infections screening; this isn't promoted nearly enough, particularly in sub-Saharan Africa, even though the evidence shows that it is fairly easy to achieve very high levels of condom use in commercial sex.
We've been very selective about our use of different HIV prevention methods. Prevention tools must work in four major ways in order for them to succeed - they must work behaviourally, technically, politically and financially - if any one of these things is missing, prevention won't work. Abstinence, for instance, works technically - you are definitely not going to get HIV through sex if you abstain - but behaviourally, studies tell us that abstinence doesn't actually work very well, so telling people to cross their legs for the rest of their lives isn't really going to prevent HIV.
Q: What is the truth within the HIV response that we're ignoring and why?
A: One of the great distortions is the gender thing; we've spent a lot of time acting like it's all about innocent women versus wicked men, when in fact it is impossible for heterosexual transmission to occur in the millions without both sexes being involved. The fact is, women like to get laid too. In sub-Saharan Africa, young women entering marriage are more likely to be the infected partner; more men will infect HIV-negative wives while married, but still, about one-third of new infections in marriage are a result of women infecting their husbands.
This fantasy of the innocent woman has led to some misdirected programming such as women's empowerment programmes and microfinance - both of which are useful, just not in the case of HIV. What should have been done is extremely aggressive promotion of condoms and sexual health services, especially in the context of sex work, much earlier on. We're still not focusing enough on commercial sex.
We've dichotomized HIV epidemics as generalized and concentrated, but even in generalized epidemics, commercial sex work contributes a much higher proportion of new HIV infections [than the general population].
Q: Treatment as prevention - is it the answer to ending the AIDS pandemic?
A: I think treatment is the answer to ending AIDS, but I don't think it is the answer to ending HIV, which is an important distinction. I don't think that it is financially feasible to scale up treatment to the levels it needs to reach in the population in order to end HIV transmission.
For those of us who worship at the altar of the randomized control trial, the recent HPTN 052 study gave us very good evidence that HIV treatment reduces infectiousness, something we've known for a while. But it has only proven this at an individual level; it doesn't tell us about the population level, whether the low viral load can be maintained in the entire population on treatment for the entire lifespan of this population while still ensuring newly infected people - who are highly infectious - are not infecting other people.
In addition, the study excluded people who were not able to adhere to treatment - that meant drunks, people who travelled for work and so on, did not participate in the study. People in the study were in a well-supported trial situation, and we don't know if we can feasibly recreate such a situation in the real world.
This is not to suggest that we shouldn't treat more people, and treat them earlier than we do at the moment. It is bound to reduce the infectiousness of people infected with HIV so it will certainly have an impact, but because treatment allows people to stay alive and sexually active for much longer it won't, in itself, be enough to wipe out new infections.
Q: In your book, Wisdom of Whores, you make the case that in Asia, HIV prevention should focus on high risk groups such as sex workers and IDUs. In East and Southern Africa, where HIV is much more generalized, what is the best way to approach HIV prevention?
A: I genuinely don't know what to do for HIV prevention in sub-Saharan Africa, and if anyone else has got ideas that really work I don't see them being put into practice. I would predict that incidence is unlikely to fall, and there's a fair chance that it will rise.
On the other hand, if it is possible to provide and keep expanding treatment at a higher CD4 count and sustain it without it undermining the progress of other health and development issues, then HIV may not - eventually - be such a big deal. Members of the 'AIDS mafia' - such as myself - won't say that HIV is not a big deal because we come from the generation of AIDS, when people died, which was a very big deal. But today, if HIV treatment is affordable and available and an HIV-positive person is in a well-managed situation, truthfully, HIV is really not that big a deal.
What I mean is it is not a big deal for an infected individual; it is a huge deal for health systems and tax-payers who have to manage the epidemic, and there is a real threat of drug-resistant strains emerging and taking us right back to the age of AIDS.
Q: In Wisdom of Whores, you say in the past the epidemiological data on HIV was presented in ways that aimed to cause alarm and spur increased AIDS funding. Has this changed - is the data we see today more reflective of the truth about the state of HIV?
A: I think it's getting harder to beat up the statistics the way we used to, and perhaps there has also been a realization that it can be counterproductive to the work you are doing - you might get the money but you can't do what you need to with it.
There is a greater realism compared to the earlier years, and I think there is less distortion even than five years ago. Perhaps lessons are being learned, or perhaps I've just been out of the UN system for too long to see what's going on.