Kevin, HIV positive and a counselor at a health center in Cote d’Ivoire, meeting with Aya, 24, who is six months pregnant with her second child. She has come to the clinic for HIV testing.
The HIV/AIDS pandemic was ten years old in 1991 when I joined the University of California at San Francisco as a young medical resident. It was a humbling time to begin practicing medicine; almost all of our AIDS patients died within two years of diagnosis.
As the world marks the 30th anniversary of the CDC’s first report about AIDS, June 5, I think back to those dark times—and of the resilience of the human spirit. For those years also marked the dawn of disease-specific advocacy and civil disobedience, movements that helped change the world.
Few imagined that, by 1996, combination antiretroviral therapy would start turning HIV into a chronic condition. Fewer still imagined that these drugs, originally priced at $15,000 a year, would reach the world’s poorest countries.
I cite this history because the pandemic is at another turning point. This time, the new research breakthroughs are in HIV prevention.
We are on the cusp of having a robust new set of HIV prevention tools. Male circumcision, pre-exposure prophylaxis (PrEP), vaginal microbicide gels, prevention of mother-to-child transmission, treatment as prevention—we now know that all of these tools can slow transmission of the virus. An HIV vaccine remains the best long-term hope, but we cannot allow the perfect to be the enemy of the good.
“Combination prevention” has a nice ring, but where should the world invest scarce resources? Two measures stand out in terms of cost-effectiveness.
First, we must accelerate the rollout of male circumcision in southern and eastern Africa. Second, we must offer treatment to infected pregnant women to protect their health and their babies from HIV infection. Both save more money than they cost and will save countless lives.
What about the recent flurry of excitement around “treatment as prevention” following the recent NIH-funded HPTN 052 trial?
It is wonderful to have proof that efficacious treatment is also efficacious prevention. We had strong evidence before, but it is now incontrovertible. However, let’s not overinterpret those results. Two-thirds of people with HIV in developing countries die for lack of access to treatment. We must focus on those who most need treatment for themselves—both for their own sake and because available evidence suggests that treating them will also have the greatest prevention benefit for others.
With today’s limited resources, it would be a shame if we relaxed our efforts to increase treatment coverage among those most in need because we overinterpret the HPTN 052 results. It may be true that all treatment is beneficial because it all has prevention benefit, but some has a much lower cost and higher benefit than others. If collectively we don’t focus our investments where they do the most good, people will become infected and die unnecessarily.
I know that these are difficult financial times, but I’m still optimistic. The crisis is forcing us to become smarter and more efficient, and get more value for money—and that will strengthen the response in the long term. We are also finally seeing real success in the development of new prevention tools.
It has been a tough 30 years, but we’ve never had as many opportunities for action as we have today.
University of California at San Francisco (UCSF), Centers For Disease Control And Prevention (CDC), Pre-Exposure Prophylaxis (Prep), Microbicides, Male Circumcision, Prevention of Mother-To-Child Transmission (PMTCT), Treatment as Prevention, National Institutes Of Health (NIH), Antiretroviral Therapy (ART), Antiretroviral Drugs (Arvs), Africa, Asia