Peter Hotez is at it again. He is the master at tricking us to care about diseases that normally we would prefer to ignore. He and his co-authors caused a bit of a stir again this week when they proposed a 32 cent “solution” for HIV prevention: treating schistosomiasis with praziquantel. Josh Ruxin called this idea “revolutionary” in a recent editorial on the Huffington Post. While I don’t agree that this is a particularly new or revolutionary idea, I do believe that there are good reasons to believe it, and that it is just too good of an idea to let fade into obscurity. So here are my two cents on the thirty two cent idea.

Schistosomiasis is a classic neglected tropical disease (or NTD as Hotez and others have rebranded them for marketing purposes). It affects millions of people, causes a massive burden of disease, and can be treated cheaply and easily. But because it does not kill people or perhaps because it does not have a huge celebrity following it gets very little attention from Ministries of Health, donors, and policy makers (I should say here that the NTDs have one celebrity: Alyssa Milano is an NTD Ambassador). Heck, even people infected with schisto and visibly pee blood due to infection neglect the disease. It contributes to the burden of disease through anaemia, kidney problems, stunted growth, learning problems. Tons of really bad stuff, and as such we should really care about it, but we don’t. Classic.

The association between schistosomiasis and HIV vulnerabilty has been speculated for some time. In a cross-section of women in Zimbabwe it has been shown that schistosomiasis infection is correlated with HIV. Of course, everyone knows that correlation does not imply causation. They could have higher schistosomiasis because of HIV or because of some unobserved confounder (e.g. lifestyle or job). That said, there are lots of good clinical arguments that could be made as to why have open sores and bleeding in your genital track could make you more susceptible to HIV, so the idea is very plausible. Eileen Stillwaggon, an economist from Gettysburg College has been talking about the “ecology of poverty” in Africa, including parasite infection, as one explanation of why prevalence is so much higher in Africa for many years.

What we do know and what cannot be refuted is that we can treat this stuff really easily and cheaply. The Schistosomiasis Control Initiative, led by one of the other authors of this paper, thanks to all of the increased funding that has been given to it by Gates and the US government, has shown that whole countries can be blanketed with treatment for a few cents a treatment and guess what: it works. The success of countries like Burkina Faso are being replicated elsewhere even while the programs are challenging themselves to do even more by delivering other NTD treatments in an integrated package.

I personally believe that the NTD control programs should be further strengthened because I think treating the NTDs to relieve the suffering of billions infected with these scourges is the right thing to do and will probably do more to alleviate poverty and promote development in poor countries. But if we need to sugar coat it and say we are doing it to prevent a disease we do care about, than I guess I am OK with that as well.

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