We got some great comments in response to yesterday’s post How the war on AIDS was lost. Much of the debate centered around three questions:
1) Isn’t treatment complementary to prevention? And so there is no tradeoff?
While some agreed with the post’s overall assertion that prevention has been neglected in favor of treatment, Caitlin argued that this distinction is artificial: “in many places, the availability of treatment makes prevention possible.”
Gregg Gonsalves expanded: “ART can reduce viral load and transmissibility. In the absence of a vaccine or a microbicide and the difficulties in achieving behavior change in general in public health, can you afford to be so categorical about AIDS treatment? Might ART provision be an important part of HIV prevention strategies?”
OUR RESPONSE: We all agree that there should not be 100% of one and zero of the other. Beyond this, we disagree. Even if treatment does help prevention, this is only partial. (Treatment is not 100% necessary and sufficient for prevention). And they are still two separate goals. So there is still SOME tradeoff between efforts that target treatment and those that target prevention.
2) Do we know how to do prevention? If not, why not?
Uganda is often cited as a prevention success story, but Justin added that “there is still a lot of debate over what actually accounts for the Uganda decline in infections, but even if we could narrow down the cause, it may not be generalizable to other countries because of different patterns and cultural practices. And even in Uganda, the trend is reversing.”
One problem is that while treatment shows obvious, life-saving results, there is more room for human messiness and error with prevention. Unsurprised wrote: “Prevention cannot be bought with aid dollars…The problem is NOT that more financial resources have gone to treatment rather than prevention, but that no one—especially local leadership—has ever been serious about sending the necessarily blunt and uncomfortable messages it takes to get people to change their sexual behaviors.”
Avam pointed to the downsides of a development economics-centric approach, and others emphasized the power of locals rather than global “experts” in figuring out prevention for their own communities. Caitlin said that many communities did “figure out” prevention in their own areas, but that these gains were not sustained or brought to other communities.
OUR RESPONSE: These are all good points, and Aid Watch is very familiar with the ideas that (1) money alone does not solve problems, including prevention, and (2) solutions arise from local people and are specific to each area. Our point was that the international effort could have helped contribute advice to prevention programs, but it didn’t because treatment effort crowded out prevention effort. In fact, Helen Epstein and Daniel Halperin have offered insights like the effectiveness of male circumcision to lower transmission and the importance of multiple long-run sexual partners in transmission in Africa. The international AIDS effort ignored them for a long time and is still not serious about applying these insights.
3) Who are the “Searchers” and who are the “Planners” in the quest for more effective AIDS treatment and prevention?
Caitlin took the post to task for leaving out local community leaders’ explanations of for how we got to where we are today. Gregg Gonsalves argued that the post pinned blame on well-known experts and funders, while “fail[ing] to acknowledge that most of the drive for treatment has been derived from local activism in Brazil and Thailand, first, then South Africa, then with help from activists most with small NGOs in the North…You ignore your own “searchers”– the “little” people who have been building up the AIDS response for 30 years and invest all the power in the planners…who come late into the game.”
OUR RESPONSE: You are right, I have been inconsistent about this. Solutions usually do arise from local searchers, and I should be more respectful of how the local treatment advocates responded to their own circumstances and found solutions, and I congratulate them on what they have achieved.
However, not all searchers have successful searches. Good economics and common sense should be injected into the debate that searchers participate in, and searchers are also influenced by the availability of resources and political capital. The result in AIDS is that there have been a lot of searchers in treatment, and far too few in prevention.
WE WONDER: Would treatment advocates now be willing to make a forceful statement about the critical urgency of prevention?
11 Comments
Hi Bill and Laura,
Thanks for responding to the comments yesterday!
In response to your last question — I think many treatment groups have done this. For instance, the Treatment Action Campaign has also been focusing lately on prevention, and groups in the US like CHAMP (Community HIV/AIDS Mobilization Project) are “building the movement for prevention justice.”
I hope that if you are going to write more about the HIV and AIDS response that you are able to meet with “searchers” and read some works beyond the usual suspects. I think that will allow for a more nuanced and constructive conversation. Let me know if you need some recommendations — I’d be happy to send them your way.
Sincerely,
Caitlin
Australia did quite well at encouraging prevention because of a policy of actively engaging with the high risk groups, particularly gays. There has been some backsliding recently because treatment has got better and younger gays in particular are less worried by it. So I guess here treatment is actually discouraging prevention somewhat.
Dear,
I was involved in the discussion when they switched from “prevention only” to “treatment is a right”. I am not a specialist, but will try to sort out my thoughts.
When they switched to treatment, in Southern Africa, there was little left to prevent. Most countries had extremely high infection rates already.
1. With Aids you don’t drop dead, you die in a protracted and humiliating agony, think about his when you advice on a course of action, leaving behind orphans.
2. Prevention of HIV/AIDS was never public-health led, but rather led by political correctness. There is no reason it would be better now. How long did it take to suspend the Human Rights of the carriers of the SARS virus in Canada? Contrast this with the totally unfocused approach of HIV/AIDS-prevention before treatment came along. Everybody was eventually at risk, and so the focus on transport and prostitution was a lot less than what would have been efficient at the start of the epidemic. What works best for the West Coast gay community is not necessarily the best for all and every other situation in the world. Using the prevention only approach South Africa saw his HIV-rate rocket from 0.5 % to lots (I wont argue on the precise figure, 25-35 % of pregnant women?) in only a decade.
3. Who cared. Let’s call it the white man’s burden?
4. A situation with 0.5 % of the population infected is not to be compared with a situation were nearly half of the girls you meet are marked for destruction.
5. Without any treatment, there is no hope and no future for the infected. This means there is no incentive to know your status, nor behavior change for the infected.
6. The epidemic runs its course. Nothing is better prevention than seeing everybody die in utter misery and agony. So the population group with risky behavior (and raped women, can be a mighty proportion of the population) dies out eventually. Leaving only god-abiding,church going, loving married couples. I have a gut feeling (not based on scientific fact) that most “success stories” are in fact just that: the epidemic ran its course, or the epidemic never took up because the behavior is just not conducive to it.
7. Tender loving care: what might be the most important question: what kind of society do you want to build. The aid efficiency approach on hiv/aids is tending to let them perish. However, to build a society with trust and networks of support, it is important to care, to care for the sick and dying, and at least try to treat.
Dear William,
Your wrote: “Treatment is not 100% necessary and sufficient for prevention”, but a paper by Granich et al published in The Lancet in 2008 showed (using mathematical modeling) that if you coulf put 99% of those infected on treatment, you could get rid of HIV in South Africa. The aim is to date rather unattainable, but it really points towards what need to be done, i.e. capacity building for VCT and treatment updtake + social change towards HIV.
This would obsviously come at a cost (estimated at USD15billions for S.Aft), but on the long term would be much chepar.
It does make sense to put everybody who is infected on treatment. This must be done as soon as possible (not taking into account the CD4 count). To date, treatment strategy benefits the individual but not the population.
Treatment as prevention (also known as TASP, T’n'T, PopART) could be the most economical prevention solution and feasibility studies are in the pipeline.
~r
I think we are ignoring the more glaring tradeoff between funding for HIV/AIDS and other diseases / development needs (including the Neglected Tropical Diseases Bill has written about before). While high funding levels for HIV/AIDS programs (prevention, care, and treatment) make sense in some contexts, it is frightening to see how much money HIV/AIDS receives in some countries when compared to other more urgent and prevalent devt needs – USAID funding for Ethiopia is a prime example.
Of course there is always a trade off between development choices, but you underestimate the importance of treatment and you overestimate the effectiveness of prevention options. I’m not sure why you think the AIDS community is not serious about applying what is known about male circumcision and concurrent partnering. Male circumcision is being scaled up albeit quite slowly because it is a clinical procedure that requires surgical skills in short supply. New technologies are being developed to simplify the procedure. As regards concurrent partnering, an application of the principle invariably would entail some sort of behavior change communication. BCC is a very blunt tool that can absorb a lot of money to little effect. The messages around concurrent partnering are tricky– it is “safer” to have multiple sequential partners than it is to have two or three steady, concurrent partners. Try getting support for a campaign that promotes that message. Besides the epidemiological impact of treatment (reducing viral load leads to reduced infectiousness), you fail to mention the behavioral impact of treatment. Before treatment, people at risk had little reason to get tested. With treatment, more people have a reason to get tested and are more likely to be counseled and more likely to rethink their risky behavior as a result. The issue with the “war on AIDS” ( I hate that metaphor) is not the lack of funding. If anything there is too much funding relative to other needs and other diseases. The bigger issue is the allocation of AIDS funding to poor uses (annual AIDS conferences, ineffective abstinence only programs, UNAIDS, unneeded advocacy).
Thank you for your as-ever interesting and challenging posts.
Not to be disingenuous, but of *course* I support the critical urgency of prevention. You can’t really think that most treatment advocates oppose the implementation of effective prevention strategies? That we, as a community, are motivated by the short-term gains of treatment programs at the expense of the long-term gains of prevention programs? I find that hard to believe. The problem is that there are very, very few implementable prevention strategies, or prevention programs to implement. Prevention of mother-to-child transmission (PMTCT) is one, needle exchange programs are another, “prevention with positives” (enrolled in care and treatment programs) is another, and widespread voluntary circumcision may be a fourth. We’re serious about these! Programs to support these strategies are being rolled out – and should be funded to roll out faster, better, and bigger. But in terms of actual, actionable, evidence-based intervention ‘packages’ that could be put into play right now…where are the others? If you were funding programs to decrease concurrent partnerships, what would you fund?
One rebuttal might be that with more funding comes more solutions – but that is a theory, not a fact. Family planning experts, local and international, have tried for 60 years to achieve changes in sexual behaviors, with only modest and intermittent success. And while the unprecedented funding for HIV/AIDS care and treatment has unquestionably fueled its impact, I would not underestimate the non-monetary variables that have led to the success of treatment scale-up, notably the grassroots advocacy, multisectoral partnerships and demand-driven programs that Gregg describes.
I fear that for some, saying they support “prevention” is like saying they support “world peace.” Irreproachable, but spectacularly difficult to put into action. For others, to be honest, calls to support prevention have been calls to limit access to treatment programs.
The world needs both prevention and treatment, and pitting one against the other may entertain the commentariat but is not likely to achieve lasting public health gains. Working to identify effective interventions, to implement them in partnership with stakeholders, and to utilize existing programmatic platforms for service delivery seems like the wisest approach.
If we look at the big “roll-backs” of HIV prevelance–gay men in places like San Francisco in the early 80s, Uganda and Thailand rather later–in none of these situations were testing, treatment or “knowing your status” important (indeed, for the most part treatment was not even available in these situations).
The “treatment is prevention” mantra tends to be based on the idea that “through treatment we lower people’s viral loads, and then they are less likely to pass the infection on.” Well, it is true that people’s viral loads will be lowered through treatment, but by the time people come to be tested their viral loads have already fallen to the level where transmission through sex is pretty difficult (dirty needles are another matter, though). The bulk of HIV infections via sex are probably going on within the first few months or so of exposure, where people’s viral loads are temporarily very high. It’s unlikely that people are going to get tested within this viral window period, and even if they did they will not be able to produce a positive result for much of that period. So, we find people who are positive and put them and treatment? That’s great for them, but in terms of prevention, it’s unlikely to make that much of a difference. If the person was going to pass it on via sex, they’ve probably already done so.
You have then also got to take into the account that treatment makes HIV a hell of a lot less scary. Worldwide, wherever treatment levels go up, the numbers of new infections tends to go up as well.
None of this means that testing and treating people aren’t important. They are important because they save people from a horrible, early death and that is good thing to do; it’s about compassion and ethics. But what this does mean is that treatment is NOT prevention. If we are going to treat more, we need to be even more aggressive on prevention. At the moment, that’s not happening.
It’s partly about politics. Everyone wants to be the compassionate politician doling out medicines to sick people. Nobody wants to be the guy talking about getting needle exchanges into jails, or talking frankly about why Southern and Eastern Africa are seeing HIV on a scale which simply doesn’t occur elsewhere.
Bill, I’ve worked in the global AIDS community for nearly 20 years, with organizations both vast and small, and was once a loud proponent of letting Searchers lead the way in the face of a sluggish “official” response. But what I’ve experienced in the past decade has convinced me that AIDS is a salient and cautionary example of the limits of the Searchers vs. Planners idea. Not only was it Searchers who enabled treatment to crowd out prevention (as you graciously acknowledged) but it was also Searchers who effectively exiled science from prevention programs, which has accounted for the lion’s share of the failure you rightly decry. What was once taken seriously (by Planners) as an infectious retrovirus has since become (for Searchers) a proxy for every manner of global ill and a vehicle for every special interest group to capitalize on to promote their particular social causes (all from a sincere belief that “their” issue must somehow be contributing to the spread of HIV).
If it were up to Planners, prevention programs would be based on scientific evidence about the specific dynamics of the epidemic in each country and context, and programs would be tailored–and limited–accordingly. In the event, however, science was long ago banished from most discussions of prevention programs, because Searchers have acquired such widespread influence over resource allocations and even the terms of the debate itself. (It is not uncommon at AIDS conferences to see scrupulous scientists being booed off panels when they disseminate data that are not to the liking of particular Searchers.) Most prevention ideas proposed and/or implemented by Searchers — which now account for the vast majority of interventions in practice worldwide — are unsupported or even contradicted by science and evidence. This is why so many AIDS programs look so similar, even across dramatically different country contexts.
The triumph of Searchers in AIDS is historically understandable, because only a broad-based coalition could have bestowed on AIDS the political support it needed to overcome its severe stigma. But it must be recognized that this victory came at the expense of science — and therefore success. Given the social dynamics of HIV, there’s no question that Searchers have a important role to play in finding how best to induce behavior change in specific social contexts, which only locals can know. But unlike many development issues, there *are* knowable rights and wrongs in biology. You aptly cite Epstein, Halperin, and other prominent specialists, who are consummate Planners all. Had Planners kept the upper hand in AIDS, prevention programs would today be more disciplined, more scientific, and far more successful than the grab-bag of well-meaning and heartwarming but uninformed ideas that now occupy too much of the global effort.
Bill and Laura-
Just catching up with these responses.
First: treatment and prevention are closely linked as others have mentioned in that access to treatment can have its own biological effects in reducing transmission, can have “social” effects in boosting HIV testing rates. Yes, handing someone a clean needle is not the same thing as handing someone a pill, but to insist on treatment and prevention being at two far ends of a spectrum of interventions is simply not true.
Secondly, you mention Daniel and Helen’s writings. Circumcision has only recently been proven to be an effective HIV prevention tool. There were vast resources devoted to these trials belying the idea that Daniel was a lone voice in the wilderness promoting this approach to HIV prevention. Now that we know it works to prevent transmission of HIV infection to men, we have to implement it. Circumcision is out-patient surgery, with its attendant risks for men and women, including the fact that men who have sex before they’ve fully healed put their partners at a higher risk of infection. It’s not a simple task to scale-up circumcision, but one that many of us along with Daniel support.
Helen’s book is another matter: she talks about reducing concurrent relationships, something that is not new and many of us have talked about, but more importantly she talks about the role of communities in responding to AIDS as the key to prevention successes, including what she witnessed in Uganda.
Despite your continued insistence to the contrary, treatment activists have been leaders in their communities on HIV prevention. In Russia, Thailand, Ukraine (among other places), treatment activists have pushed for access to clean needles and methadone. In Jamaica, Botswana, Uganda, Nepal, treatment activists have pushed for prevention services targeting men who have sex with men. In South Africa, India, Brazil treatment activists have fought against violence against women which puts them at high risk for HIV infection.
Furthermore, AIDS activists have branched out further and farther: some are working on access to sanitation, to education, health care labor issues, microfinance, to refugee rights–we are an eclectic bunch despite your caricatures of us.
I am one of those treatment activists who have spoken out on prevention and have worked on it for many years. You say there aren’t enough searchers in HIV prevention, well, there are, but the field is dominated by academics and CDC folks who have narrow conceptions of what HIV prevention should look like. No one has ever asked in the USA or elsewhere why prevention has failed despite the investments made in it. It’s convenient to say: oh, it’s treatment’s fault, they have all the money and if we had some, we’d do better. Many of us, from Julie Davids at CHAMP, Dan Wohlfeiler at the CA Dept. of Health, Mindy and Bob Fullilove at Columbia, Walt Senterfitt in LA, Richard Elovich in NYC and others have tried to get the field to examine itself, try new approaches, but the resistance is overwhelming.
And finally about searchers. It seems you only like them if they share your views on economics and common sense. You want acolytes then, more than anything else.
Are there problems with the AIDS response? Yes, I’ve written about them for years. But we have been a band of searchers, fighting governments for what is good for our communities, trying whatever works to keep people from dying, from getting infected. Not everything we’ve done is right, but we have a much better track record of success than many of the “health and development experts” who led the field to ruin in the 80s and 90s, paving the way for the epidemic(s) of HIV and TB, for the decay of health systems.
Towards the end of her book, Helen Epstein writes: “But some cults are positive. They start with ideas that get people talking and they develop into social movements that change things for the better. Until we find the magic bullet, this is the only cure.”
Sadly, your greatest achievement may be the destruction of the “invisible cure,” the social movement that may have started with AIDS, but has branched out widely in the past 30 years, and which has been the foundation of real successes in prevention, treatment and care for AIDS and in a host of other areas.
We share your frustrations on the failures of health and development over the past decades, but we’re part of the solution, not the problem. Perhaps one day, you’ll recognize that.
Yes, there are many ways to approach HIV prevention, but the efficacy of ART for prevention simply is far greater than any other prevention intervention studied to date.
Gregg
HIV drugs prevent infection in African study
Drugs reduced transmission by 92 per cent
BY MAGGIE FOX, REUTERSFEBRUARY 17, 2010 8:11
WASHINGTON – People across Africa who took AIDS drugs were far less
likely to infect their partners with the virus, researchers said
Wednesday.
The study, presented at a meeting of AIDS experts, is one of the first
to show so clearly that the drugs can prevent infection as well as
keep patients healthy. It could boost efforts to provide the AIDS
drugs to people, especially in the hardest-hit countries in Africa.
Dr. Deborah Donnell of the Fred Hutchinson Cancer Research Center in
Seattle and colleagues followed 3,400 couples in which one partner was
infected and the other was not in seven African countries.
The couples were all counseled on how to protect themselves and given
free condoms. Each patient with HIV began taking a drug cocktail when
he or she became eligible based on a measure of immune system damage
called CD4 count.
Over the next one to three years, 103 of the previously uninfected
people became infected. Nearly all, 102 infections, happened before
the infected partner started taking the drugs, Donnell told the
Conference on Retroviruses and Opportunistic Infections in San
Francisco.
“Only one happened when the partner was on antiretroviral therapy,”
she told reporters in a telephone briefing.”That amounts to a final
reduction of 92 per cent when on antiretroviral therapy.”
The AIDS virus infects 33 million people globally and has killed 25
million since the pandemic began in the 1980s. There is no cure and no
vaccine but combinations of drugs called antiretrovirals can keep
patients healthy.
There is a debate over whether treating patients also reduces the
likelihood that they will infect others. It is an important point as
governments and non-profit groups spend billions on treatment and
prevention programs.
“We think it is very likely that antiretroviral treatment is going to
reduce the risk of HIV transmission,” Donnell said. “Our data will be
informative for policymakers.”
Donnell said the study was unique as the couples were followed closely
and tested every few months. Tests showed whether newly infected
partners were actually infected by their sexual partner or by someone
else.
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