Comment by RGS1811
11 hours ago
While HIV vaccine research is an exciting field, it's worth pointing out that halting HIV transmission is, practically speaking, a solved problem with oral and injectable reverse transcriptase inhibitors. The ongoing loss of life and health due to HIV could be stopped if we cared enough to invest resources in wide-scale PrEP availability and public health education. Waiting for an HIV vaccine is the domain equivalent of hoping fusion power will solve our energy needs. Other solutions exist already; we just have to use them.
You could say the same about teen pregnancy being a practically solved problem, except there is still the problem of teen pregnancy. Or even something more mundane as driving consistently safely all the time to solve the problem of accidents.
If everyone was disciplined all the time in regard to everything, many problems in the world would simply not exist. But we live in reality where for whatever reason, people don't know to do something, or they do know and they're just not disciplined, or they make a mistake due to extenuating circumstances. And I would expect that the vast majority of people would oppose any idea of somehow punitively "dealing with" people who get some things wrong.
So I would say that it's very evidently not a practically solved problem, because if it were we wouldn't be looking to solve it still.
Within this reality, a vaccine is a great additional tool at solving the problem of preventing the spread of HIV.
> You could say the same about teen pregnancy being a practically solved problem, except there is still the problem of teen pregnancy. Or even something more mundane as driving consistently safely all the time to solve the problem of accidents.
At the risk of derailing this conversation from the original topic, those two things are not remotely equivalent. There's no organized political movement trying to tell people that seat belts and speed limits are immoral, and you should only drive when you're willing to accept the responsibility that comes with the risks.
Where I am from, organised political movements are not a factor of teen pregnancy and were not the least bit in my mind when I made my statement.
And my two examples are completely arbitrary because my point applies to pretty much any problem which would be solved by people being “more careful”.
So, political/religious elements aside, teen pregnancy and road safety are the same in terms of “if people were just more disciplined, there would not be these problems” (i.e. if teens who have easy access to contraceptives planned ahead before giving into impulsiveness; if drivers were more attentive to their behaviour), which I then pointed out is naive because the reality is that people aren’t perfect, they aren’t always disciplined, we’re all only human.
Hence, we need other solutions to help with problems which don’t require ignoring that people are only human and lack perfect discipline.
I agree that some organised movements can be a problem in that they can make other problems worse.
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derailing further, it's no organized political movement, and they don't call it immoral but in Caucasus region some men avoid using seat belts as "unmanly", and that's a very social thing. Small plugs into a seatbelt socket to shut up the car audible warning are very common, including taxis.
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Teen pregnancy (or unwanted pregnancy at all) has been extremely low in several countries, and the factors are not discipline but was of access, focus on health instead of morality, and public service campaign. If it is high in an otherwise rich country, it’s likely not a lack of discipline from teenagers but a lack of free and easy access to contraception and abortive means, social pressure and morality campaigns, lack of sex education (often by design sometimes by negligence after some period of activity)
" likely not a lack of discipline from teenagers"
You two might be using "discipline" pretty different. Your definition of discipline would encompass constant casual sex as long as contraceptives were used and any abortions were prompt, right?
FYI teen pregnancy in the US is the lowest it’s ever been in the history of the country.
Right, but we know that HIV/AIDS essentially is a solved problem in rich countries, that the mentioned interventions are readily available in rich countries, and the only reason HIV transmission is high in poor countries is because, well, they're poor. We (humanity as a whole) have plenty of money, we could fund these things, we simply choose not to.
I would caution against making an allusion to self control. It would be very cruel to act as if people who get a disease through no fault of their own could have avoided it, and most people who contract HIV could not. You may not have intended to make that allusion, but you did.
> So I would say that it's very evidently not a practically solved problem, because if it were we wouldn't be looking to solve it still.
This is obviously not what is meant by "practically solved problem". Everybody knows it is not actually solved.
I recently read "Everything is Tuberculosis". It describes a similar issue with the rich / poor country divide.
It's quite sad and difficult to read at times.
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"the only reason HIV transmission is high in poor countries is because, well, they're poor."
This is factually untrue.
Being poor does not equal a HIV transmission rate. There is no 1:1 correlation.
A single protected (condom) sexual act between a male and female averages somewhere around 0.1-0.5% chance of pregnancy, and during the fertile window it could still be around 1% or more even with a condom.
Chance of HIV from one act of unprotected vaginal sex with an HIV-positive partner: ~0.08% male-to-female.
The high HIV transmission rates are NOT correlated with wealth, but social behavior. Unprotected anal sex with many partners? High risk. Now, Africa - the practice of dry sex contributes a ton to HIV transmission. Cultural belief that a dry vagina increases pleasure, hence woman use sand, chalk or bleach to dry out their vaginas, massively increasing HIV risk. Needle sharing of drug users? High HIV risk.
Not a class issue, no reason to punch down on poor people. Poor people have agency and many do not infect themselves with HIV in the first place.
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No, there will always be the threat of teen pregnancy. Conversely, we could wipe out HIV permanently if enough public will across the world was directed toward it.
I fully believe that HIV wouldn’t exist if PrEP had come out in the 80s when public hysteria was at an all-time high and the will to eradicate it was present.
We haven’t even managed to wipe out polio, and that is a cheap, lifelong vaccine.
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>if PrEP had come out in the 80s when public hysteria was at an all-time high
You mean the time the US admin was intentionally neglecting the epidemic because "it's a gay disease"? Why do you think Reagan would have done anything to ensure such a medication was easily available?
> And I would expect that the vast majority of people would oppose any idea of somehow punitively "dealing with" people who get some things wrong.
Of course, and for good reason. The ones who know for a fact they are right, might in fact be wrong or malicious.
I thought the current panic was that young people (not necessarily teens) weren't having enough kids?
Which is in fact panic that teens are not having enough children, because that's where we have seen big drops...
This whole "panic" seemed weird from the start, but once it becomes clear that it's from the lack of teen pregnancies it takes on an even creepier Epstein-like oddness.
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Taking teen pregnancy as an example: we have the tools to avoid it. We have condoms, we have birth control, we have the morning after pill, we have abortion. We have all the tools -- are more tools really going to help? The fact that teen pregnancy is still an issue is not because we lack the tools to solve it.
HIV prevention is similar. We already have the tools. We have condoms. We have PrEP. Sure, a vaccine would be nice, but if someone is unwilling to go on PrEP, why would they suddenly be willing to get a vaccine?
Another tool isn't going to hurt, obviously. But it also isn't the #1 highest leverage place to be spending our time if the goal is to reduce HIV transmission. (It is, however, a great use of time to develop a vaccine if you're profit-motivated. HIV prevention is a massive business. 1 year of PrEP in the US costs $20-30k, although luckily ACA mandates $0 copay. I could imagine a $50k HIV vaccine being a blockbuster drug especially if ACA also mandates $0 copay - tons of money to be made! Ugh)
Edit: To be clear, I'm excited there's a promising vaccine. However, I am not getting my hopes up that a vaccine will magically cure all of the social/political issues getting in the way of a vaccine actually being widely distributed and administered.
> but if someone is unwilling to go on PrEP, why would they suddenly be willing to get a vaccine?
Because PrEP at even its best and most modern version requires an update every six months for life. If you're well-off and in SF or NYC or London that might be easy, but there's so many externalities such as:
- People who misjudge the risk they're at, so don't go on the meds in the first place
- People who live in regions where getting to a doctor even every six months is a challenge
- The six-month injection is extraordinarily expensive and a life-time treatment, for a disease you don't even have yet.
If instead it becomes a once-in-a-lifetime series of shot, like many other vaccines are already, we can start considering a path to extinguishing the disease, not just teaching people to live with it.
Then there's the financial savings of a series of three shots once vs a lifetime of them.
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That's like asking "if someone is unwilling to practice abstinence, why would they be willing to wear a condom, or to flip a magic 'not fertile right at this moment' lightswitch?"
A vaccine is something you do once and PrEP is something you have to continue to do over time and get overcharged out the ass for the entire time and worry about if it will remain available in the future.
It's still killing people like crazy (and spreading) in undeveloped nations. The new drugs are un-cheap.
Also, I believe that we just DOGEd our only vehicle for distributing these to underdeveloped nations.
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All the tools we have against teen pregnancy need teens making right decisions, or taking corrective actions.
If there were a pill that'd block pregnancy for X years, given at the age of Y, then parents could enforce it and teen pregnancy would be solved (also it'd be very cruel but I'm just trying to make a point so bear with me).
Going back to our topic: People could also forget PrEP, be drunk and forget to wear a condom and so on. If this vaccine (or vaccine series) creates a somewhat permanent protection, it'd make a huge difference.
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Unfortunately HIV is not a solved problem.
Condoms? They break. More frequently than you might think.
Truvada and Descovy are great and make a big difference, but they require either high adherence to taking pills daily or being able to plan ahead for 2-1-1 (for same-sex relations - it's effectiveness for heterosexual intercourse hasn't been determined).
Apretude and Lenacapavir obviously require getting to a doctor or someone who can give you the injection either every other month or twice a year, is expensive, and can be very painful for some days afterward. And, of course, they're expensive.
A vaccine is the only real option for dealing with HIV for good.
The hardest problems to solve that actually matter are in humanities.
All your arguments are sound, and I'm still missing your point. Pharma is interested in doing pharma, indeed. But who's interested in your solution, assuming you have one? A significant part of the current electorate (internationally, even) seems to abhor sex ed, condoms, abortions and all that. So tell me again please how you suggest we address teen pregnancy - in THIS world.
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It's a solved problem if you are someone that knows you'll be exposed to HIV in the very near future and you have the money and wherewithal to purchase PrEP before that event (and you can plan the event 7 days out).
The power of a vaccine is you can give it to adults and kids before they are sexually active and protect them, potentially, for the rest of their lives.
I'd also be curious to know if the combination of ART + the vaccine might cure someone of HIV. Which is also a pretty big deal.
This is completely inaccurate. There is PrEP that requires dosing two times a year. You can also get PEP if you engage in a risky activity without PrEP.
Yes, it exists, but how available is it really? If I recall correctly, the injections are also not very pleasant.
"Gilead sells LEN at very high prices (over $28,000 per person per year in the US), severely restricts its supply to certain countries, and refuses to sell it directly to Doctors Without Borders/Médecins Sans Frontières"
Source: https://www.doctorswithoutborders.org/latest/campaigns/acces...
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That PrEP is in some ways similar to a vaccine, and there is still a lot of value in getting a better vaccine (cheaper and/or lasting longer).
Also, PrEP pills can have side effects long term. And distributing huge amounts of daily pills to remote areas of the globe is much harder than the patients getting a shot on their yearly medical visit.
> I'd also be curious to know if the combination of ART + the vaccine might cure someone of HIV. Which is also a pretty big deal.
"Cure" in the sense they could become indefinitely under detectable levels. It's worth noting that to really cure a person of HIV you'd need to remove all mutated cells.
Ad-hoc use of PrEP just requires that you take a double dose 1 hour prior to potential exposure, and follow up with another double dose 24 hours later, at least with the versions commonly prescribed to sexually active groups in my area.
I agree that a vaccine is another game-changer, but it’s extremely important that we don’t spread misinformation about the efficacy and convenience of PrEP. In developed societies, it has already all but eliminated new transmissions among groups that were previously most at risk.
At least 2 hours before, not 1, and preferably closer to 24 hours before.
Does this double dose completely prevent infection?
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Cost and compliance are still 2 major factors that have not been solved.
We also have education and stigma. While within the LGBT community it is far more common to be open about status and taking prep and doxy (far from perfect though), it still feels like outside of that the conversations are not happening as much as they should.
Throw in doctors that are not being proactive about the conversation.
Right now it seems like having prep and doxy is largely considered only if you are engaged in "risky" behavior (not saying that in a judgmental way to be clear), instead of just being sexually active and protecting yourself. Money and investment alone won't fix that, that is a societal shift around how we talk about sex.
That is also before we get into the cost issues in many other countries just for those that do need it.
PReP has some side effects. While they are rare, they are things you need to be aware of. If you are not doing risky sex it isn't for you.
Most people want to believe they are in a monogamous relationship and thus not having risky sex - even though they are the one cheating. Either PReP needs to be more common, are people need to stop their risky sex activities (that they are not even admitting to).
> If you are not doing risky sex it isn't for you.
That blanket statement I very much disagree with. Sure there are side effects but that is part of why you also get tested every 3 months for liver issues (not that it is the only side effect, but still).
Instead of it being a blanket statement it should be a conversation with your doctor about the pros and cons.
You can still get HIV even if not engaging in risky behavior. Same with people getting pregnant when they did not intend too.
I am thinking college kids that are still figuring out their sexuality and exploring new things. You're going to make mistakes so having a conversation about prep with your doctor is a really good idea.
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All sex is risky by this measure.
Condoms break. Partners lie. Shit happens.
It doesn’t take a lot for the risks to far outweigh any potential side effects. As far as I’m aware, every healthcare system in the developed world either recommends or enforces checkups after starting PrEP.
Compliance is the big thing.
Vaccines are the "an ounce of prevention is worth a pound of cure"
PrEP is freely available in the UK and there is almost no requirement in practice of engaging in risky sex. I don't know anyone turned down for not having risky enough sex
Which countries are you talking about out of curiosity?
The LGBT community should also think about abandoning some risky practices which allow infections, and promote antibiotic resistance in the case of doxycicline "prep".
But I guess that sex without condoms is worth it, right?
Any solution to a public health problem that involves moralising about how groups should change their behaviour is not only doomed, it’s actively counterproductive.
And doxycycline is a PEP treatment, not a PrEP treatment; respectfully you should probably take a step back from conversations where you obviously aren’t informed about the basics.
> But I guess that sex without condoms is worth it, right?
Not speaking about LGBT related matters; Sex without condom is just like everything else - it depends on the person. For some people there is little to no difference. For others, wearing the condom removes all sensation, reducing the act to physical exercise. So is sex without condoms worth it? For some people, yes, it is.
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It is endemic in the simian population. It will keep crossing over into humans again and again. It has done it before several times. People who live near forests would have to be on Prep everyday of their lives. The reason they eat bushmeat is the because they are poor and will be too poor to afford daily medication. A once-and-done vaccine would at least stop new crossovers. Only then could we really get a handle on ending this disease world-wide.
HIV did not exist in human population before XX centiry. Crossings from SIV are extremely rare - vaccinations is about HIV, not SIV
This is the wrong take. You are basically arguing that if we have one solution, why bother having a second one?
"Grandma needs to stop taking her statins and just exercise" type shi
Transportation was a solved problem with horses, doesn't mean the car isn't a good idea. Same for internal combustion and EVs.
A vaccine is an objectively better solution than PrEP, just because of the time scale, PrEP needs discipline on a daily or x-monthly basis. A vaccine could last for years. Although, realistically, it's more likely to end up requiring yearly updates like COVID, because HIV is also a mutating son of a bitch.
I 100% agree that waiting for a vaccine is stupid beyond measure. The world should do both: make PrEP widely available AND keep funding vaccine research.
Isn’t prep more like a prophylactic, as opposed to a a vaccine?
I’m more familiar with malaria, where the preventative medicines are currently more effective than the vaccines.
The analogy to malaria is pretty on point. Pre-Exposure Prophylaxis (PrEP) is, you nailed it, prophylactic. It's not as good as a vaccine would be, and it's not as cheap as a one-and-done shot, but we've gotten to the point where you can get one shot every six months (lenacapavir) and, it's 99%+ effective at preventing infection. And, much like with malaria, the prophylaxis works— there is currently no HIV vaccine that reliably prevents infection.
"Prophylactic" is a broad-enough word to encompass vaccines, as well, so I'm not sure what you're getting at. It just means something that defends against disease.
prep is great but i would really rather take a one-time vaccine than be expected to take an expensive pill forever that could mess up my liver
Which one do you suppose the pharmaceutical companies would prefer?
I’d guess the ones developing the vaccine would rather you take the vaccine
The company making the expensive pill you take forever would prefer the pill. Competitors who don't make those pills would love to develop a vaccine and put that first company out of business.
who do you expect to create pharmaceuticals other than pharmaceutical companies? sheesh
I'm sure they will gladly sell us both
There are some dubious metaphors in use here. Public health is not about math problems to be “solved.” “A solution exists” is just a milestone. “We just have to use them” - yes, but leave out “just,” there is more to do and it’s hard.
The answer to “are more tools really going to help” is always going to be “it depends.” Promising interventions sometimes fail entirely. If they statistically improve outcomes, that’s a win. Only occasionally is a disease entirely eradicated.
> If your solution to some problem relies on “If everyone would just...” then you do not have a solution. Everyone is not going to just. At not time in the history of the universe has everyone just, and they’re not going to start now.
https://www.tumblr.com/squareallworthy/163790039847/everyone...
PrEP is difficult on the body over time and though it can be used if you are high risk you are meant to avoid certain medications while using it and have to do follow ups with your doctor to check organ functions.
A few people I know on PrEP have annoying uncomfortable side-effects. Vaccines are largely more tolerable, especially on a discomfort/time metric.
There's still a huge difference between a one off injection and lifelong tablets.
From a convenience factor, sure, but both effectively turn a death sentence into a solved problem. I believe GP was pointing out that we should prioritize funding for the existing solution until the more convenient one is available.
For rich people (meaning the ~3 billion people that have some sort of access to medical infrastructure), it is a solved problem, but there are quite many people without any access to it. Even for those "solved problem" people, taking a pill every day to be protected is inconvenient. They might not take it every day, etc.
Also, even if it were a solved problem, the methodologies developed here can probably help with other viruses too in the future. This has already happened with the antivirals originally developed for HIV.
I was 16 when Magic Johnson announced he had AIDS. That was the first time it felt real to me. I remember a couple of friends crying because we all thought he would be dead in 1-2 years. And here he is and seems to be living a normal life.
He doesn't have AIDS, he's HIV-positive.
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Again, inaccurate. You can get a PrEP shot twice a year now.
Access is a valid point. Perhaps the money being used to fund a superfluous vaccine should be used to fund access to PrEP in the Third World.
> Perhaps the money being used to fund a superfluous vaccine should be used to fund access to PrEP in the Third World
An astounding statement. Is it not possible that a vaccine giving decades of protection would give better health outcomes than doing PrEP every 6 months?
Or maybe we should solve poverty which is a proxy to all kinds of solved problems that somehow still exist
Those on prep would welcome a vaccine, it would be a significant improvement. I agree that this is no reason to take the foot off the gas with prep availability, we need more ASAP.
Is it not available in pharmacies?
Very dependent on locality. Mine requires a prescription for every refill, and I must continually meet certain risk criteria to qualify.
"The ongoing loss of life and health due to HIV could be stopped if we cared enough to invest resources in wide-scale PrEP availability and public health education."
It wouldn't be stopped, only slowed. You would still have transmission from accidental or unknown exposure. You would also have a small portion of the population that didn't care, regardless of the education.
As we all hopefully learnt from COVID-19, slowing sufficiently is the same as stopping. It’s a numbers game. Slowing transmission below some threshold will eventually mean that there are no new transmissions.
Then why aren't STDs, TB, etc, eliminted. Even heavily vaccinated diseases are still around and pop back up occasionally. The only one eliminted was smallpox.
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Are people still getting infected? Yes? Then it is not a solved problem.
it's actually an interesting question: is there a point where the long acting prep injections have effective durations that look like vaccines and boosters. and yes, sadly, it appears that convenience and some of the psychological aspects of marketing play outsized roles in public health.
either way, worth doing. you never know when circumstances might change and another tool in the toolbox becomes essential.
Who's waiting? The problem is the populations we need to distribute it to can least afford it.
The reason we want a vaccine is because there's a huge logistics difference between a twice yearly injection and the real magic of something more like an MMR shot where one dose is usually effective for life.
In the global south a significant barrier is the lack of sex education, driven by local christian associations, which have significant power in local societies. They see it as "gender ideology" or as preventing births and thus being against the bible.
My hiv exposure was from an SA, I wasn’t on Prep. This will still save lives!
This isn't just about HIV, it's about finding new ways to approach viruses. HIV wasn't the first and won't be the last virus we don't have a way to stop. This research adds to our knowledge about ways to attack some of the trickier viruses.
Everything is a "solved problem" if you're willing to ignore a variable (usually money or human life/toil).
It's a solved problem for people in stable environments, who can follow instructions, take medication, etc.
It's a problem that was "solved" long before that by just wearing a condom and protecting yourself against other diseases too, and even pregnancy. Condoms are cheap, widely available and decades of condom-related education has been given out to many different generation of kids and adults worldwide.
Somehow we still need day after pills, abortions, antibiotics and other STD meds, and vaccines, now (hopefully) for HIV too.
And they suck. Everyone who's ever worn one knows they suck. If they're too big they completely kill all sensation, if they're too small they cut off circulation, leading to, you guessed it, total loss of sensation. Topped off with the fact that they fail during higher friction activities (you know, exactly the kind that drastically increase HIV transmission risk), they're never going to be an adequate solution, because there will always be people who'll risk it, because what's the point in having sex if you're not going to feel it anyway?
> Somehow we still need...
So, clearly condoms are not the complete answer. Any solution that does not acknowledge the reality of how people actually behave is going to be imperfect.
We live in a messy world.
If only Isaac Asimov had worn a condom, he might still be with us today.
Public health education means getting gay men to start wearing condoms or dental dams and apparently that's a bridge too far for them.
The total refusal for anyone at scale pretty much anywhere to use dental dams is particularly egregious:
https://www.theatlantic.com/health/archive/2019/04/dental-da...
https://slate.com/human-interest/2021/08/no-condoms-gay-sex-...
https://www.washington.edu/news/2024/02/27/qa-decline-in-con...
https://www.huffingtonpost.co.uk/entry/prep-condoms-gay-sexu...
At least a portion of the amount of people "in the closet" are closeted for fear of STDs, not particularly because of social stigma risk.
Project 2025 vehemently goes against of it. Why was I downvoted? I am right. The american government strides in lockstep with P25 and corruption.
Long history of not wanting to address the epidemic:
https://en.wikipedia.org/wiki/Ronald_Reagan_and_AIDS
Nobody else said it, so I will. Halting HIV transmission is a solved problem if people are willing to give up sex with untested strangers. The same is true of syphilis, monkeypox, and every other sexually transmitted disease. It says a lot about human nature that a small number of people would rather have society spend vast sums of money researching and developing prophylactics and vaccines instead of changing their own behavior, while the vast majority have enough self-control not to catch diseases through random sex.
> The ongoing loss of life and health due to HIV could be stopped if we cared enough to invest resources in...public health education.
It's definitely a problem of caring, but not one of education: there are not honestly many people out there who don't know that random sex leads to diseases, but there are some people who just don't care enough to prevent their spread. If they did care, they would have sex only with known, tested partners. Minimizing harms through additional investment of resources just leads people to continue to fail to care, at society's expense.
> ... a solved problem if people are willing to give up sex with untested strangers
It's wired into our DNA to do this, and while we can be socialised out of it, you'll never get anywhere close to the near 100% you'd need.
It's not a small number, and like you point out, this is human nature, so asking people to stop is pointless. If people always acted rationally and with empathy for others, everything would be much easier. There would have been no Covid pandemic, no global warming, no drunk driving, and so on.
Yet here we are, needing laws, cops, vaccines, and so on. Asking people to only have absolutely safe sex due to its external effects is about as useful as asking them to stop eating meat due to its external effects.
Besides that, PrEP has enabled the return of non-HIV STIs in major cities like Berlin where a lot of the community has returned to raw-dogging since the AIDS-Scare has become a historical artifact.
Is that a huge problem? Doesn’t almost everything else have a prophylactic and is curable? Hep-C might be the only other one I believe and I’m unaware if it’s treatable or not.
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Most things are a solved problem if we give up the things that make life worth living. Obesity is a solved problem if you just eat for health. Road traffic deaths are a solved problem if you never leave your house. Suicides are a solved problem if you just don't kill yourself.
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Literally no one asks for proof of an STD test before sleeping with them. You might ask someone if they have STDs and use a condom but that’s how 99.99% of how people sleep with other strangers.
Abstinence has been shown to be an extremely, hilariously, stupidly ineffective strategy in all questions of human sexual health.
The HIV/AIDS epidemic would not have been nearly as serious as it was if people like you and the Catholic Church hadn’t advocated for it over all other measures.
It doesn’t work. Change your mind.
I agree but asking your partners to get tested is not abstinence
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So in other words… it’s not a solved problem. What point are you trying to make?
This is the brainlet version of the correct take, which is "anal sex without condoms is objectively bad from a public health perspective".
If compliance with safe sex techniques were anywhere close to where it should be, this wouldn't be a problem.