Fighting the HIV epidemic in the Islamic world.

2058 www.thelancet.com Vol 381 June 15, 2013 Early in the HIV/AIDS epidemic, most predominantly Muslim countries regarded HIV as a disease associated with sexual promiscuity, homosexuality, and drug and alcohol use—behaviours forbidden by Islam. Home to more than 1·6 billion Muslims, the Islamic world was widely believed to be somehow protected against HIV/AIDS. Adherence to Islamic beliefs, together with widespread practice of male circumcision, was thought to protect against the risk of HIV infection, and subsequently to account for a comparatively low HIV prevalence in Muslim majority countries in sub-Saharan Africa and the Middle East. 30 years into the epidemic, the reality is vastly diff erent. HIV infection is a concern in several Muslim majority countries including Malaysia, Indonesia, and Iran, with prevalence rates in adults of 0·4%, 0·3%, and 0·2% in each of these countries, respectively. In most parts of the world, the HIV/AIDS epidemic has stabilised or decreased; however, of the nine countries where incidence rate has increased more than 25% since 2001, fi ve—namely, Bangladesh, Indonesia, Guinea-Bissau, Kazakhstan, and Kyrgyzstan—have Muslim majorities. Furthermore, the number of people newly infected in the WHO Middle East and north Africa region has increased Fighting the HIV epidemic in the Islamic world The other approach to tackle HIV persistence in patients taking ART is to lure HIV out of its hiding place in resting T cells. Activating latent virus might lead to death of the cell or make the virus ready for immune-mediated clearance. A range of licensed drugs that modify gene expression, including viral gene expression, are in clinical trials in HIV-infected patients on ART. Two studies have reported that HIV latency can be activated with the histone deacetylase inhibitor vorinostat. There are now 15 HIV-cure-related trials being done worldwide. Clinical trials include investigations of increasingly potent histone deacetylase inhibitors, and of gene therapy to eliminate the CCR5 receptor from patient-derived cells. HIV-cure-related trials raise many complex issues. Giving potentially toxic inter ven tions to patients doing very well on ART needs careful assessment. At this early phase of research, participants will be unlikely to derive any direct benefi ts. Understanding risk–benefi t, ethical issues, and the expectations and perspectives of the community will all be discussed and debated at IAS 2013 and the preceding IAS workshop, Towards an HIV Cure. Developments towards a cure for HIV are exciting— for scientists, for clinicians, and most importantly, for patients. But we need to be realistic. Finding a cure will be a long and tough road, and will take many more years to achieve. We are at the very beginning, although many now believe that it might be possible to fi nd a cure, at least for a small proportion of infected people. We need to take inspiration from the many people who have delivered so much in the past 30 years, and continue to imagine, continue to innovate, and con tinue to work together towards an HIV cure—for everyone.