AIDS has been with us, officially, for 30 years, since the U.S. Centers for Disease Control and Prevention reported the first cases. This unhappy anniversary is perhaps as good a time as any to spell out why the global response to AIDS is in need of serious adjustment.
Annual spending on AIDS worldwide has risen to $15.9 billion. The bulk of this money goes to the treatment and care of indigent people who are HIV-positive. Without question, the investment in anti-retroviral therapy, or ART, has saved lives. Today, the treatment is provided to about 36 percent of those in the developing world who qualify for it under World Health Organization guidelines.
United Nations member states have pledged to raise that to almost 100 percent. Universal treatment has become the principal mission of many AIDS organizations around the world; governments and philanthropies have followed their lead.
The idea of treating everyone who has the human immunodeficiency virus, regardless of ability to pay, is laudable. The problem is, the laudable runs the risk of crowding out both the practical and the doable. As programs for treatment have grown, those focused on prevention have languished or gotten short-shrift.
A couple of examples: Studies in 2005 and 2006 showed that circumcision reduced a man’s chances of becoming HIV-infected through vaginal sex by roughly 50 percent. Yet circumcision efforts remain spotty where they are most needed, in the 13 countries in Africa that have generalized AIDS epidemics and relatively low circumcision rates.
This is especially troubling given that male circumcision, which costs about $55 on average in Africa, is arguably the best HIV prevention method available for men. It requires a one-time effort rather than the constant discipline of using condoms or taking ART daily as a prophylactic.
According to a study by the Results for Development Institute, it would cost $921 million to achieve, by 2015, male circumcision rates of 80 percent in 22 low- and middle-income countries with serious HIV epidemics.
For years, doctors have also known that transmission of HIV from a mother to her newborn can be prevented by administering ART to the mother during pregnancy and to the infant after delivery. This practice helped reduce infection rates among children born to HIV-positive mothers by 26 percent from 2001 to 2009.
Still, last year an estimated 430,000 babies around the world were born HIV-infected -- children who might have been spared had this targeted approach received more significant support. Results for Development estimated it would cost $3.8 billion to ensure that, by 2015, 80 percent of HIV positive pregnant women received this intervention in the 22 countries studied.
This isn’t to say that it’s unreasonable to give drug treatment pride of place -- ART not only improves the lives of the infected but, according to a new study conducted by the HIV Prevention Trials Network, it also can stop the virus from spreading. When HIV-positive individuals were on anti-retrovirals, the risk that they would infect their sexual partners was greatly diminished.
What’s more, apart from male circumcision and treatment for expecting mothers, there aren’t a lot of highly effective, practical HIV prevention strategies available. Education and condom campaigns rely on asking people to change sexual behavior, and so have had limited success. These programs also depend on altering entrenched cultural norms, like presuming that women, who bear 60 percent of HIV infections in sub-Saharan Africa, will always be able to negotiate the terms of sex and condom use. The use of ART as prevention for those who aren’t infected might hold promise were it not so costly.
Many in the AIDS community now argue that everyone who tests positive should begin drug treatment immediately -- rather than when their CD4+ white-blood-cell count drops, the conventional practice. But starting ART early means risking side effects and drug resistance sooner. The HPTN study found just one potential health benefit for the HIV-positive partner, a reduced chance of contracting extrapulmonary tuberculosis.
Then there’s the question of cost, particularly when compared with other measures. AIDS groups have done an admirable job of negotiating with drug companies to reduce ART prices for the developing world. A year’s supply of a first-line therapy costs about $168 there. But the price more than doubles when it includes the repeated check-ups that anyone on anti-retrovirals must have, because the drugs can cause liver, kidney, nerve and blood problems.
Results for Development estimates that increasing the percentage of HIV-infected people on ART in the developing world to 80 percent by 2015, from the current 36 percent, would cost $38 billion. Expanding the availability of male and female condoms to four-fifths of people at risk of HIV in 22 countries by 2015 would cost $4.2 billion.
In theory, it’s hard to be against a universal ART policy. In an age of limited resources, though, it doesn’t make sense -- especially if that policy crowds out effective preventive measures and robust research to develop new ones, like a microbicide vaginal gel that blocks the virus, or an HIV vaccine, which could actually end the pandemic.
Total global investment in microbicide research fell by 3 percent in 2009. Funding for vaccine research likewise has diminished.
AIDS provokes big emotions, as it should. The world has seen nothing like this pandemic since the Black Plague in the 14th century. Its death toll, 33 million, is just one measure of its devastation. The passions stirred by AIDS have driven both the development of HIV drugs and their rollout to poor countries at reduced prices.
Yet there is also a place for cool reason. In this fourth decade of AIDS, governments, philanthropies and activists need to realign their priorities, understanding that it will be possible to provide treatment to every HIV-infected person only if we can, through prevention, greatly reduce the numbers of those who carry the virus.
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