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To end AIDS, high-risk countries will need to jab schoolgirls

Two decades ago HIV was ripping across Africa like flames across a lake of petrol. In some countries more than a quarter of adults were infected. Nearly all were expected to die, slowly, leaving families without breadwinners and forcing girls to drop out of school to care for sick parents. Sober observers predicted social collapse. But then the price of antiretroviral drugs plunged: pills that not only kept people alive but made them less infectious. By a conservative estimate, they saved 21m lives.

Why, then, is AIDS still the top cause of death for African women and number three for women aged 15-49 worldwide? The answer is that, although 30m people with hiv are taking the pills, 9m are not. Those who do not know they have the virus can easily pass it on: 1.3m people were freshly infected last year and 630,000 died of the disease, which ravages the immune system.

The UN has set a goal of ending AIDS as a public health threat by 2030. Ideally, someone would invent a cure or a vaccine, but neither is likely soon. So two approaches must be pursued simultaneously. First, find people who are HIV positive but don’t know it, and offer them drugs to keep them healthy and uninfectious. And second, stop uninfected people from catching the virus.

All this could, in theory, be accomplished with existing technology. But persuading people to get tested is hard. People with HIV may experience no symptoms for years, and men are often reluctant to visit a clinic when they feel well. As for prevention, condoms work, but only when people use them, which many don’t. So another tool is generating excitement: pre-exposure prophylaxis, or PrEP. Today this means a daily pill that dramatically cuts the odds of contracting HIV during sex. It works for gay men in rich countries, but is suboptimal for the largest high-risk group: heterosexual women in poor places where HIV is common. Taking a daily pill is a hassle, and hard to conceal from a jealous boyfriend in a cramped home.

A long-lasting injection would be more discreet, less bother and, unlike a condom, require no negotiation with a recalcitrant partner. ViiV, a British drug firm, offers a new jab that lasts two months and has licensed it to generic manufacturers. Gilead, an American firm, is testing a drug that could last for six months.

Some states and ngos already give prophylaxis to drug injectors and sex workers. If the six-month injection works, it should be routinely offered to teenage girls in high-risk countries (a fifth of South African adults are HIV positive). Mass jabbing in schools would be controversial, but probably effective.

Young people who are not yet having sex are unlikely to have the virus. In sub-Saharan Africa it is the girls who typically get it first, by sleeping with older men (who, unlike schoolboys, can pay for dates). When the girls are older, they pass it on to partners closer to their own age. If transmission from “sugar daddies” to teenagers is broken, a younger age cohort could grow up virtually virus-free.

Drug prices will need to be negotiated. But every new infection means a lifetime of treatment, which costs on average $380,000 in rich countries and $5,000 in poor ones. So it should be possible to devise a programme that saves money in the long run. Donors can drive a hard bargain by buying PrEP in bulk.

The size of the prize makes it galling that some Republicans are blocking the reauthorisation of PEPFAR, America’s global AIDS programme, which expires on September 30th. (Some object that it doesn’t stop recipients from mentioning abortion.) They should pick a different battle. As George W. Bush, PEPFAR’s founder, puts it: no programme could be more pro-life than one that saves millions.

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Updated: 29 Nov 2023, 05:00 PM IST

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