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AIDS Politicking Drowns Out a Message of Flexibility

Health reporter Laurie Garrett is a fellow of the Council on Foreign Relations.

If there is one take-away message at this year’s International AIDS Conference, which ends here today, it is that there can be no single, simple approach to successfully combating HIV and AIDS. Unfortunately, it was sometimes hard to hear the message through the din of politics and polarization.

Thousands of protesters and participants, angry that First World treatments are still largely unavailable in the Third World, have been insisting that the best way to fight AIDS is to put millions of people on anti-HIV drugs. Although there clearly is a moral imperative to bring the medical miracles of the wealthy to the poor, example after example here proved that treatment should not trump prevention. After all, studies in the United States and Europe show that an ever greater percentage of new HIV infections -- nearly 30% today in America -- involve drug-resistant strains of the virus. That means that those being infected had unsafe sex with partners who were on the medicines and who not only spread the disease but made it harder to treat.

The sheer scale of the epidemic also underlines that treatment is no “cure.” There are 5 million new cases of HIV a year worldwide, with numbers doubling or tripling annually in some hot spots like Eastern Europe. So what is the best approach to preventing the disease? Flexibility, creativity and doing everything possible.

In Uganda, for instance, the government claims HIV “prevalence” dropped from 30% in 1990 to 5% today. Yuweri Museveni, Uganda’s president, told the conference that the key to success was a campaign that pushed abstinence before marriage and fidelity after marriage. That no doubt helped, but in southern Uganda, the country’s only long-term study shows that the number of new infections there dropped by about 40% between 1990 and 2002, without any significant changes in general sexual behavior. The only factor that changed, according to the study, was an 80% rate of condom use between casual sex partners.

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Unfortunately, the U.S., which should be the world’s major player in fighting HIV/AIDS, is concentrating only on Museveni’s message. The much-trumpeted $15-billion President’s Emergency Program for AIDS Relief, or PEPFAR, makes its help contingent on prevention plans that emphasize only the Museveni approach. Congress and the White House generally oppose spending on condoms or on sterile syringes. Yet even the congressional General Accounting Office, in a report released this week, cites those restraints as an obstacle to PEPFAR’s success. Politicians may not like the idea of handing out sterile needles to heroin users, for example, but New York City researchers pushed HIV among drug injectors down from a 1990 high of 50% to 15% in 2002 with such a program.

I was in Hanoi earlier this month when the U.S. government decided to add Vietnam to its list of 15 nations targeted for help under PEPFAR. I saw bewildered health officials there trying to figure out how the U.S. money, with its political constraints, could be used effectively, given the drug use and prostitution that are driving the spread of HIV in that country. And the U.S. isn’t the only one falling prey to the impulse to oversimplify. The World Health Organization announced in Bangkok that it would reduce by half the percentage of its HIV budget spent on prevention next year, while increasing spending on treatment. The agency offered no clear explanation for this decision, other than political pressure (remember those protesters and activists?) to get anti-HIV medicines to poor countries.

The problem with that strategy was quantified at the conference. The World Bank did a cost-benefit analysis of funding HIV treatment in India and concluded that the direct costs of providing drugs would be recouped, in the form of a surviving labor force. But it also found that those economic benefits could be erased and the epidemic could swell if India failed to execute a safe-sex condom campaign at the same time.

Surprisingly, it was PEPFAR Director Randall Tobias who may have done the best job of summarizing the situation in his speech at the conference. “Preventing AIDS is not a multiple-choice test,” he said. “Those who want to simplify the solution to just one method -- any one method -- do not understand the complexity of the problem.”

It is time his bosses hear that message and broaden the U.S. efforts. It’s time to fully fund treatment programs and prevention programs. Overemphasizing any approach, or, more accurately, oversimplifying the problem, guarantees that at the next International AIDS Conference, in 2006, the world will be facing a pandemic marked not by 5 million new cases a year but tens of millions.


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