Thinking about the potential use of a vaccine to control or eliminate the spread of HIV has been present since the earliest days of the epidemic.
Vaccines Don’t Work Without People
Thinking about the potential use of a vaccine to control or eliminate the spread of HIV has been present since the earliest days of the epidemic. The identification of the virus led to overly optimistic estimates of the speed with which a vaccine could be developed, tested, and put into practice. One-time Secretary of Health and Human Services Margaret Heckler’s view of the world through rose-tinted glasses led at least some to believe that a vaccine would be in use by 1990. Now, nearly 20 years later, vaccines remain in the future.
From a policy perspective, the concerns are many. What if the first vaccine developed is only effective against a limited strain of the virus that is infecting few people? What if the vaccine mostly works to boost the immune response of those already infected? What if the vaccine does prevent infection but at a very low success rate, such as 25% of those vaccinated? What if we have a vaccine that works better than that, but the delivery system in the most affected parts of the globe is so fragile that it cannot support distribution? What if belief in the implied guarantee of a vaccine leads to an increase in risky behavior? And, of course, who pays for the whole thing anyway?
The behavioral and structural challenges associated with introduction of an HIV vaccine are significant. Many of the areas of the globe for which the vaccine is held out as a hope are those where existing resources are strained beyond the breaking point. When specific HIV-related services are offered as a part of demonstration projects or research efforts, they have the luxury of economic and logistical support. There are staff incentives, such as training programs in capital cities and the exciting presence of experts known from literature, conferences, or satellite broadcasts. The programs are insulated from the day-to-day stresses of trying to offer HIV-related services, maternity services, healthy baby initiatives, malaria control programs, tuberculosis treatment, and emergency services with too few staff, irregular supply lines, and huge patient populations-factors that describe the everyday reality in many of the neediest communities.
Within just a few years, the health services in the developing world have been asked to plan for, implement, and manage prevention of mother-to-child transmission, HIV testing, and antiretroviral therapy, not only in teaching hospitals and cities but also across wide swaths of rural landscape. There have been successes, but there also have been serious challenges, and progress has been far slower than desired. Most recent pushes have been on the treatment side, not the prevention side. Prevention currently depends on a complex mix of education, motivation, recognized self-worth, and access to condoms (and sterile syringes, if drug injection is involved). Sustained success has been limited and is easily reversed by a change in political priorities, leadership perspectives, or economics. The ability of one influential religious leader to derail global polio eradication efforts should be taken as a clear warning. Discouraging polio vaccination not only has maintained levels of paralytic polio in the immediate region but also has led to outbreaks in multiple locations, which are fueled by travel. The only somewhat surprising positive impact of economic and political collapse has been seen in Zimbabwe, where the effort to survive in the face of hyperinflation has apparently changed social behavior with regard to multiple sexual partners and thus reduced the transmission rate of HIV.
As another instructive example, the failure of US policy regarding the seriously mentally ill should be considered. The advent of successful management of schizophrenia and bipolar disease with pharmaceuticals rightly led to the emptying of the large warehouse-style mental hospitals across the country. Unfortunately, the successful management of these diseases requires much more than the simple distribution of pills once a week or once a month. It requires ongoing human support networks, safe housing, and access to regular health services to manage not only the diagnosed mental illness but also medication adverse effects and other health problems. No state has been successful in developing and maintaining this network of services at the level needed to avoid a return to the challenge faced by Dorothea Dix in the 19th century: more mentally ill people in jails and prisons than in mental health service institutions.
No matter how successful a vaccine eventually is, it will not administer itself: a full range of storage and distribution services will be needed, along with the personnel to educate patients, administer the vaccine, and keep appropriate records. In addition, because not everyone will immediately be protected from infection, the full range of HIV education and prevention support services will still be needed. Finally, vaccination does not remove the need for ongoing treatment and support of those already infected. Technology is only part of the answer; people are critical. We should be working now to be sure we have the “people production” pipeline in place to complement the vaccine development pipeline.
Where Do You Go for Information?
While the AIDS Reader audience is generally well-informed and stays up-to-date on a wide range of issues, there may be some who do not yet have a wide perspective on resources for policy-related information. It is altogether too easy to use one or two sources of information and accept their coverage with little question. Policy issues always have multiple facets, and every policy option has at least one drawback, no matter how positive the reaction to it.
As an easy example, many in the HIV world would love to see pharmaceutical prices drop and the use of generics increase, even if it means a decline in the profitability of some companies and the downsizing of others. More medications that are affordable means treatment for more people-an easy win. But, many pension funds find pharmaceutical stocks to be an excellent investment, one that ensures dollars will be there, possibly for your retirement and mine. And every downsizing translates to layoffs: one more person struggling to find the next job and faced with the need to continue health insurance coverage under COBRA with a markedly reduced income that puts monthly premiums out of reach. The good may outweigh the bad, but we should not jump on any policy without answering the questions “Compared with what?” and “What is the downside?”
Where to turn? For basic HIV information and resources, as well as information on adopted policies, the Web sites of the CDC (www.cdc.gov), World Health Organization (www.who.int), state health departments, and some large, local health departments are very useful and usually interlinked. For advocacy positions related to US funding, the AIDS Action Council (www.aidsaction.org) is an outstanding resource. The perspectives of the various health professions may be found on their association and society Web sites, and, because many professional perspectives do not converge, looking at the views of those in other specialties is beneficial. For careful analyses of both HIV and general health policy issues, the Kaiser Family Foundation (KFF) Web site (www.kff.org) is not to be missed. Particularly useful are the daily briefs the KFF develops on general health policy, HIV, and women's health (daily emails with summary information and links). The fact sheets, longer analyses, and tutorials on this Web site can be extremely useful.
Finally, do not rely on broadcast media for your news. The brief time afforded stories on most radio and television news outlets is just too short; even National Public Radio, the Public Broadcasting Service, and the British Broadcasting Corporation are limited. Subscribing to one of the larger papers (New York Times, Wall Street Journal, Washington Post) will give more comprehensive stories and background information. For those interested in Washington, DC, news but unable to deal with a daily paper, the Washington Post Weekly is convenient.
These are just a few hints; you will add your own possibilities to the list. From a policy perspective, the more information, the better.