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Still Losing the AIDS Fight
Washington Post
October 9, 2007

by Richard Holbrooke

On the day you read this column, an estimated 12,000 people worldwide will contract HIV. Ninety percent of them, about 10,800 people, will not learn they are infected until full-blown AIDS hits them -- in 2015. Until then, those people will unintentionally spread the virus that lies silently within each of them.

But on Dec. 1, the 19th annual World AIDS Day, political leaders and international health officials will, once again, tell the world that although the fight is far from over, progress is being made. The fight is indeed far from over -- but don't believe the second half of such statements.

It is heartening that more than 2 million HIV-positive people are on lifesaving antiretroviral drugs (ARVs), thanks to generous programs from the United States, the European Union, the Global Fund, the Gates and Clinton foundations, and others. Americans should take pride in the fact that, with official aid of over $13 billion since 2003, the United States has led the world in a manner that evokes generous programs of the past such as the Marshall Plan.

But real progress must be measured by the only criterion that ultimately matters: Is the number of people who are HIV-positive declining? The answer is a resounding no. The number of people infected each day still far outpaces the number of people going on treatment each day. Anthony Fauci, the famed director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has stated the case in dramatic terms. Speaking in July at an international conference, Fauci said: "For every one person that you put in therapy, six new people get infected. So we're losing that game." He went on to say, "Clearly, prevention must be addressed in a very forceful way."

As a strategy to defeat HIV-AIDS, focusing primarily on treatment will never succeed; it can only keep (some of the) people already infected alive, and then only as long as they take ARVs every day for the rest of their lives. (If they stop taking ARVs, even for a few days, their infection will probably become drug-resistant.)

The only way to reverse the spread of the human immunodeficiency virus is to focus on prevention. If ever an ounce of prevention was worth a pound of cure, this is the case, since HIV lives undetected in people for about eight years before it explodes into full-blown AIDS. Here's the problem: More than 90 percent of the world's HIV-positive people do not know their status and unintentionally spread the virus for those eight years -- to their wives, lovers, people with whom they share dirty hypodermic needles, almost anyone.

With a vaccine apparently a decade or more away (another major clinical trial failure was announced last month) and a safe microbicide for women still eluding researchers, prevention needs immediate emphasis and far, far more resources. But most of those fighting HIV-AIDS -- dedicated, hardworking people -- are still reluctant to admit that current prevention strategies are failing. A viable prevention strategy would encompass education and counseling, free condoms, female empowerment, more male circumcision, and abstinence.

But none of this will work without widespread testing -- highly confidential but highly encouraged (which can now be done with simple, cheap 15-minute tests). I have been criticized in the past by some in the international health community for advocating testing, on the grounds that it would violate people's privacy. This is, of course, not my intent: Confidentiality must be respected.

And attention must be paid when Dr. Fauci speaks. Along with former president Bill Clinton, he is one of the few who have publicly advocated vastly increased testing as part of a strategy to stop the spread of HIV. (Even in the United States, according to the Centers for Disease Control and Prevention, at least one in four Americans with HIV do not know they are infected.) In no other medical epidemic in modern history has detection been such a low priority. But because HIV is sexually transmitted, it still carries stigmas in much of the world, including, until fairly recently, the United States. Those with AIDS lose jobs, are thrown out of their families, are denied medical help and are left to die alone. These appalling but widespread reactions lie behind long-standing international guidelines that testing should be completely voluntary.

Here is my challenge to the international health community: This year, tell the truth on World AIDS Day. Admit that we are still losing. Advocate strategies that emphasize prevention and detection, based on the successful "opt-out" testing systems being tried in Botswana, Lesotho and Malawi. If current policies are not changed, we will face uncontrollable growth in the costs of treatment of the victims of a disease that should be, as Bill Clinton has said, completely preventable.

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