The End of AIDS is in Sight

I saw my first case of HIV/AIDS in 1979. I hope to be alive for the last reported case, and with a lot of luck, that may come true.

There is no vaccine for HIV and no new vaccine realistically promising. No cure for HIV is in clinical trials. HIV treatment works well, and persons infected with HIV have an excellent prognosis, if they seek the right medical care soon enough. These traditional saviors — vaccines and cures — are not going to help me realize my goal of watching the HIV vanish from mankind.

Authoritative groups have recently touted “treatment as prevention,” but this will never work. While it is true that a person whose blood is undetectable for the virus is not likely to transmit, there are 2 main reasons this strategy will fail: (1) people stop their medicines; after 2 weeks of non-adherence, HIV RNA is right back up to baseline; and (2) a small minority of individuals account for the bulk of transmission, and these “super spreaders” have not yet tested positive for the infection.

The most typical HIV spreader is a young man who is very sexually active with numerous, sometimes anonymous partners, but yet he is not ill and has not been tested. Only half of new HIV infections cause any symptoms at all, and those with symptoms typically have a self-limited (2 weeks or so) infectious mononucleosis-like syndrome. Then, on average, it takes over 8 years to go from HIV-positive to get the symptoms of AIDS. So, many spreaders are feeling well and only get tested late, just because they are in a high risk group.

No, the answer to the HIV/AIDS epidemic lies not in the infected spreaders, but in the uninfected recipients who must protect themselves.

PreP stands for Pre-exposure prophylaxis. The currently approved PreP preparation works great, but it will not end the epidemic. This is because it is a pill. People stop taking their pills all the time. If they are not feeling ill, they are more likely to stop taking their medicine. If a medicine has a negative connotation about your self-worth, and you have to go through the refill process, you are even more likely to stop it. No, a pill is not going to rid the world of HIV.

I am pinning my hopes on PreP by injection. PreP by injection works to protect uninfected individuals, but I expect it to be more reliable than a pill. It does not require much active participation on the at-risk individual’s part — they merely need to show up occasionally for an injection. There are two products now in late-stage clinical trials that look (so far) like they are well tolerated, will do the job, and will last after each shot for 1–3 months.

If injectable PreP were promoted and made widely and conveniently available, spreaders would have no susceptible targets, and HIV/AIDS would vanish.

Winkler G. Weinberg, MD

I have been an Infectious Disease physician for over 3 decades. I am the author of No Germs Allowed!. If you liked this article, check out the book on Amazon.