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[This piece appeared in the Guardian special supplement on World AIDS Day 2003]

Stopping the pandemic

Will the next 10 years be worse - or better? What are the long-term solutions that might finally turn the tide of HIV/Aids?

In 2000, the United Nations' sixth millennium development goal pledged to "halt and begin to reverse the spread of HIV/Aids". But the World Health Organisation subsequently forecast that the number living with HIV would increase from 42 million in 2003 to 87 million by 2010.

Nor will it stop there. In September, Roy Anderson of the Imperial College school of medicine, predicted that the Aids conflagration might not peak in countries such as India and China until 2075, unless we find the decisive intervention that, to quote Bill Clinton,"could stop Aids on a dime".

What might such an intervention look like?

In some places, the old safer sex messages still work. Although the figures may overstate the case, a study funded by the Nelson Mandela Institute recently claimed that new cases of HIV occurring among South Africans aged 15 to 49 had declined from 4.2 infections per 100 people a year to 1.7 per 100 a year in 2003. This has been accomplished largely by the African ABC mantra, repeated on hoardings the continent over: Abstain, Be faithful, and use a Condom.

But condoms, faithfulness and abstention campaigns can only do so much. Condom use always faces opposition from institutions such as the Catholic church. Cardinal Lopez Trujillo, in charge of Vatican social policy, recently claimed that condoms had tiny holes that the HIV virus could get through. Women in many cultures find themselves unable to insist that men use them. And their use among gay men has been declining. According to San Francisco writer Kirk Read: "The condom is over. People are just over them."

Treatment for those now dying of Aids is, of course, essential, and its lack is a moral affront. However, in countries where half the people are not burying the other half, the terror of death by Aids no longer holds the same sway, as those who would have died stay healthy and libidinous enough to infect others.

In the UK, heterosexual HIV infections caught here have doubled since 1996. Meanwhile other STIs are showing even sharper rises. Chlamydia has risen by 140% in women since 1996 and syphilis has increased tenfold in men.

So what new tools are available to us in HIV prevention? We can probably forget vaccines for the near future. The only large-scale vaccine trial yet mounted resulted in failure, and HIV has shown itself as adept at becoming resistant to vaccine-generated immunity as to drugs.

Microbicides - chemicals that block HIV and which can be included in sexual lubricants - are a lower-tech solution. A vaginal microbicide may be ready for widespread use by 2010.They give some control of sexual safety back to women, and should not have the unwanted side-effect of stopping conception.

But chair of the British HIV Association, Professor Brian Gazzard, is sceptical about their use. "They may face the same barriers to cultural acceptability as condoms," he says. A survey of Zambian schoolgirls came to the same conclusion. "Fine for prostitutes but not for us," was the verdict.

"The answer may lie in pre-exposure prophylaxis," says Gazzard. Pre-exposure prophylaxis means you could give a daily "Aids pill " to the highest-risk people - prostitutes and their clients, young gay men, drug injectors - to forestall any chain of infection before it had time to take hold.

The Bill and Melinda Gates Foundation is funding two studies, one in southern Africa and one in Cambodia, to find if a daily dose of the drug tenofovir could prevent infections in high-risk women. The ultimate solution to a global epidemic may lie in giving HIV drugs to people without HIV.

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