Dichotomy alert: AIDS prevention vs treatment debate re-emerges

Today is the day after World AIDS Day. Things are pretty much the same.

Flickr, Benny Sølz.

Ruminating on the crazed repetitiveness yesterday of the news stories for this issue du jour, I felt a slight irritation crawling up from the lizard portion of my brain. Something in the torrent of AIDS stories yesterday nagged at me.

What was it? Like a bad aftertaste, or a fly buzzing around my head.

Whoa. It was the old AIDS treatment versus prevention debate. What some call the ugly dichotomy (which, by the way, only seems to apply to poor countries) is re-emerging. People are beginning to say we need to shift away from treatment in favor of prevention.

Oh no, here we go again …

For example, experts at the Institute of Medicine on Monday called for basically de-emphasizing treatment in Africa and putting our money into prevention:

“Because treatment will only reach a fraction of those who need it…preventing new infections should be the central tenet of any long term response to HIV/AIDS in Africa,” said Dr. Thomas Quinn, co-chair of the committee that wrote the IOM report.

Mead Over, at the Center for Global Development, wrote a much more entertaining article advocating the prevention emphasis by bashing former President George W. Bush in “What Bush Got Wrong on AIDS.”

Bush had written an op-ed in the Washington Post about one of his administration’s most celebrated accomplishments, PEPFAR, the massive scale-up of getting AIDS drugs to poor communities in Africa.

Over criticized Bush’s call for getting AIDS drugs to more of those in need:

Given our fiscal crisis, we cannot do everything.  If we accept that AIDS patients currently on treatment have an entitlement to continued support, President Bush’s call to scale-up treatment likely means less money for the rest of PEPFAR’s mandate – which is to prevent infection so that fewer people will need treatment in the future.

I’ve seen a few other articles along the same lines, arguing that due to the economic downturn the rich nations of the world should abandon the goal of universal access — of eventually making sure everyone who is HIV-infected has access to the drugs they need to stay alive and avoid the infection blossoming into AIDS.

It sounds prudent to make the case for prevention. There are some exciting new tools in the prevention war chest, as I wrote about yesterday, and we are still a long way from reaching all those who need AIDS drugs.

But we’ve had this debate before. As Albert Einstein said, the definition of insanity is doing the same thing over and over again but expecting different results. De-emphasizing AIDS treatment, as if it is somehow an alternative to prevention, may not be insane. But re-hashing this old canard won’t get us too far.

“Treatment is prevention,” the AIDS activists (when we had AIDS activists) used to chant. The point they were trying to make is that treatment and prevention are two sides of the same coin. You can’t beat AIDS without both of them.

More importantly perhaps, recent research done by the UW’s Connie Cellum and others have shown that treating HIV-infected people reduces viral load to the point where they don’t transmit HIV to others. Treatment truly is prevention.

Further, due to many of the international communities efforts such as PEPFAR and the Global Fund to Fight AIDS, TB and Malaria, many poor countries like Rwanda or Cambodia are actually on track to achieve close to universal access, according to a recent WHO report.  Will that progress unravel without continued support from the developed world?

(Fun fact: The Global Fund sought about $20 billion from governments and donors this year — and got about half that. According to Gen. David Petraeus’ top logistician in Iraq, interviewed by PRI, we spend $20 billion every year just to to air-condition our military tents in Iraq and Afghanistan.)

As Paul Zeitz, co-founder of the Global AIDS Alliance, wrote in the Huffington Post, the Obama Administration is backing away from meeting the U.S. funding commitments to PEPFAR and the Global Fund. The problem is not an issue of whether to fund prevention or treatment, Zeitz says, but of overall funding:

The world has demonstrated significant progress in preventing and treating HIV/AIDS. But now, severe funding cutbacks threaten such progress, including a virtual flat-line of U.S. funding. America made a promise to be at the forefront in the HIV/AIDS fight. Our integrity is at stake.

Alanna Shaikh, writing for End the Neglect, issues a similar warning about the impact of funding cuts on access to treatment and noted many standard prevention efforts aren’t working. Shaikh also said:

The idea of treatment as prevention gained credence. Universal access to ARVs will reduce transmission, and the more people – especially donors – who understand that, the better.


About Author

Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.