If you read about the early history of the HIV/AIDS epidemic in America, it is hard to not be struck by the public health consequences of apathy and discrimination of policymakers, health service providers and researchers. These were my feelings when I read “And the Band Played On: Politics, People, and the AIDS Epidemic”, by Randy Shilts, a few years ago. The tragedy is that many of the same issues Shilts wrote about 22 years ago are still alive in Africa today.

Men are doing particularly badly in the epidemic. Less of them are on the treatment (combined antiretroviral therapy or cART) and they present to treatment programmes later in the disease and so their survival is less than women. In particular, the combined stigma of HIV/AIDS and homosexuality in many countries in Africa has led to reduced prevention, reduced treatment, reduced use of health services and worse outcomes for homosexual men in Africa. Male-to-male sex is illegal in thirty one countries, potentially leading to the death penalty in four.

Randomised controlled trials in Kenya, South Africa and Uganda have shown that circumcision reduces a man's risk of acquiring HIV by 50%, but it appears that his female partner will not be protected. A study published this week looked at over 900 HIV-positive, uncircumcised men, aged 15-49 and allocated them randomly to immediate circumcision (intervention) or circumcision in 2 years time (control). HIV-uninfected female partners of the randomised men were enrolled at the same time. The overall risk of female HIV infection at 24 months was 22% in the intervention group and 13% in the control group. The trial was actually stopped early due to no effect of circumcision on male-to-female HIV transmission. An accompanying editorial highlights the complexity of tackling HIV/AIDS, stating that circumcision is still an important intervention, not just for protection of men without HIV, but also because it is a rare opportunity for men with and without HIV to present to health services.

Although it is still known as a neglected disease, AIDS has the unique status of having a UN agency devoted to it, and international funding for treatment and prevention programmes has not been lacking. There were, however, two cautionary messages in the Lancet this week. Firstly, unless programmes measure how many people started on treatment, stay on the treatment (adherence), then programmes will fail and any gains will be lost. This is illustrated by the fact that 40% of patients in sub-Saharan Africa were no longer on treatment after 2 years. Secondly, the previous director of UNAIDS, wrote, “…we have only just begun to see a return on the investments of the past decade in the form of falling rates and fewer deaths, indicating a new phase in the AIDS response; it by no means suggests that the problem is anywhere near solved.” You can’t do anything without long-term funding.