I'm further confused by your polio reference, because that sort of effort would only be possible with a vaccine.

I should have been more specific - I meant that if we did develop a vaccine, then it makes following the [smallpox] example theoretically possible, but this is still extremely challenging due to the reasons given.

Although you and I might have the vaccine, not everyone has it - not by a long shot - because not everyone is born in a modern westernized hospital. These people are protected by virtue of an extreme mobilization to literally isolate every single instance of the virus. It (hopefully) only exists in the lab at this point.

Polio is unfortunately still "in the wild" in certain areas (Afghanistan/Pakistan/India, Sub-Saharan Africa), and had a bit of a resurgence lately. The Gates Foundation is putting a lot of effort into finishing up polio eradication.

Relevant TED talk: http://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio....

One of the main issues is that the polio vaccine requires a cold chain (presently; I think they have a new shelf-stable one); the smallpox vaccine, at least one of them, does not.

http://arstechnica.com/science/news/2011/09/polio-in-india-g...

http://en.wikipedia.org/wiki/Herd_immunity

But a 50% decrease in new HIV infections is huge!

[EDIT: wording]

My understanding is that many (all?) of these studies have been conducted in sub-Saharan africa. The environment in which AIDS spreads may be very different in developed countries. The presence of secondary infections, unhygienic conditions, and other social norms may play a big role in the spread of aids and greatly amplify the protection that circumcision provides. The evidence does look compelling.

Now, if the infection rate is already low, secondary STDs are rare, hygiene is at a very high standard, and transmission vectors are different, then the effects might be much less pronounced. I suspect it would be hard to create a controlled study of this in Europe, since you'd have to convince a large number of men who are probably in a very low risk group to be circumcised.

One question, that I don't think has been answered sufficiently is that the controlled trials and published studies have been criticized for possibly overstating the effectiveness of treatment. (The trials were stopped early on ethical grounds which can overestimate the effects being tested.) Wikipedia has a fairly comprehensive roundup: http://en.wikipedia.org/wiki/Circumcision_and_HIV#Randomised...

I think my bigger point, though, is that it's easy to look at data and say, "Aha! This one thing is the solution" without stepping back and looking at all the different pieces that make up the big picture. It's going to take some combination of education, prevention, vaccination, and health policy to tackle this disease.

Except there have been dozens of randomized, controlled studies that show circumcision significantly reduces risk of infection.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fj...

http://www.sciencedirect.com/science/article/pii/S0140673607...

http://www.sciencedaily.com/releases/2006/12/061213174708.ht...

http://journals.lww.com/aidsonline/Abstract/2000/10200/Male_...

If that were the case here it would make vaccination much harder, though still possible of course.

The adherence part is the most interest bit of the story. The adherence to HIV medications is ~93%, much greater than the adherence to almost every other drug or behavioral treatment. If diabetes patients or cardiac patients had adherence rates anywhere near that high then the life expectancy of the average American would be dramatically higher.

- expected or actual efficacy

- regimen complexity

- knowledge, commitment, and ability

- doctor-patient relationship

My understanding is that with HIV a lot of money has been spent on actually implementing the adherence research in order to reduce the spread of the disease, whereas for most other diseases no one really cares. I think getting diagnosed with HIV also encourages some people to grow up a little bit in a way that getting diagnosed with high blood pressure or whatever doesn't, though maybe less so now that infection vectors are changing.

Diabetes (type 2) and cardiac disease are scenarios where people can still kid themselves to a certain extent.

India would probably just violate the patent, claiming national security reasons, and sell it for ~production cost throughout the world. The USA might enforce a patent domestically, and it would be a rational economic choice for insurers to pay for it for many patients instead of long-term treatment if someone contracts AIDS otherwise -- if you have a 0.1% risk of contracting AIDS in a lifetime, and lifetime treatment costs $1mm, it's worthwhile to pay $100-$1000 for it.

A charity (or government) might pay for full rights to the vaccine globally, and then distribute it for the good of humanity (and to burnish their reputation), but the really out of the box thing would be for a consumer product company to distribute the vaccine cheaply, purely as a form of PR. Imagine: "Coca-Cola, the drink that is good for you. Remember, we cured AIDS."

I think his point is that much of the problem of preventing the spread of HIV has less to do with the science of killing the virus, and more to do with the difficulty of actually getting it in the hands of people who need it. There are already very cheap, readily-available ways of preventing HIV transmission (condom use comes to mind), but people aren't using those. The reasons are varied, but some cite misinformation, cultural misconceptions, government ineptitude, and so on. Even if there were a 99% effective HIV vaccine that were as cheap as water, it still wouldn't make it into the hands of every person in the developing world. Proof of that is the fact that we can't even get water to all of these people.

Not sure how good an analogy this is. I suspect it would be moderately expensive (i.e. on the order of a few billion dollars), but possible to deliver a liter of clean water to nearly everyone in the developing world. The problem is, that solves their water problem for about 12 hours, if you're being generous. Solving their problem long term is the hard part. With vaccines, you only need to visit the people a finite number of times, and then you're done. Given that HIV is sexually transmitted (and assuming that the vaccine can be given relatively young), you wouldn't even need especially frequent visits to immunize the next generation of people.

Here's a relevant TED Talk about pandemics: http://www.ted.com/talks/larry_brilliant_wants_to_stop_pande...

"Herd immunity" protects the others -- basically, the disease itself can't spread if a sufficient number of people are vaccinated, so it dies out in a few generations (of the disease, not of humans).

The problem is the standard models of herd immunity depend on some simplifying assumptions which may be true in livestock, but are not true in humans -- specifically, that it's a homogenous population with equal chance of giving any other individual the disease, and that vaccines will be distributed fairly randomly as well.

If you have backwater villages which never get vaccinated, and are highly interconnected, you can end up with persistent reservoirs of disease, even if it's only 1% of your overall population. Then, you can have periodic epidemics when an individual from that area travels to an unvaccinated area elsewhere (because compliance rates on vaccination go down once the disease is "cured" in a population).

(I know about this from drinking with some of the UN/WHO vaccination people in Afghanistan)

I think things should work out well in the end, but it might take a while.

There are places where the official government-endorsed treatment for HIV was sex with a virgin. There are religious notions that declare use of birth control sinful. There are moral police that call education about safe sex (instead of abstinence) wrong, despite its proven efficacy.

Except the side effects (as with any drug therapy) can be severe. And the effects of long term use is anybody guess. Many patients who lived, just now reaching their 50's; are experiencing everything from diabetes to chronic kidney and liver disease to macula edema.

Course the trade off is death. So maybe it is a good deal.