The War on HIV
One of the great global-health triumphs

Outside an HIV clinic in Nyagasambu, Rwanda


Patrick Brennan

As a result of PEPFAR and the U.S.’s funding for multilateral programs, more than 4 million Africans are now receiving antiretroviral treatment — up from 50,000 in 2002. Further, testing programs and MTCT prevention were vastly expanded. (Notably, South Africa’s Western Cape province, not controlled by Mbeki’s ANC, had already begun running its own program with a cheap, basic drug called AZT, saving many lives.)

Further, the new prominence of MTCT prevention is an important instance of how the treatment programs the U.S. has provided have been crucial in slowing the spread of HIV. Anyone who is being treated with ARVs has a much weaker presence of HIV (a lower “viral load”), making him or her much less likely to pass the disease on to others. Thus, when the West finally committed to funding treatment programs for Africa (and other at-risk regions, such as the Caribbean), transmission rates started to drop, and millions of people who would otherwise have died are still alive. Because the life-saving effects are ARVs are so obvious, and HIV is so feared, the drugs’ adherence rates have tended to be remarkably high, despite some seriously unpleasant side effects. Rates of faithful use have been much higher than condom compliance ever was, making them, in many cases, a better prophylactic.

And the relationship between viral loads, treatment, and the virus’s spread is salient in another way, too, that has troubled liberal assumptions: HIV’s presence is much stronger in a person’s system in the few weeks after he contracts the virus, making him more likely, by orders of magnitude, to pass it on to a sexual partner during that time period. In fact, in the absence of other risk factors (such as other sexually transmitted diseases or an otherwise weakened immune system), the risk of passing on HIV after that initial period is low enough that an epidemic basically can’t be sustained. But in a variety of African contexts, multiple partnerships, such as between one man and several women in his community or elsewhere, are so common that an infected person often had many chances to pass on the virus during that dangerous period. The liberal response was to accept this rotten, deadly culture and merely suggest that it be conducted “safely.” But years of utterly blind condom distribution and sexual education barely raised safe-sex rates at all, and the virus flew across Africa.

It wasn’t until the 2000s that, in the light of some encouraging evidence from Uganda and other nations, liberal taboos were eschewed and a more comprehensive strategy was adopted by most global-health organizations. That called for a threefold “ABC” (abstinence, be faithful, condoms) approach, which — combined with the U.S.’s offer of much greater investment in all levels of HIV/AIDS programs and increasingly effective and well-funded public-health programs in some African countries — has finally begun to turn the tide of HIV infections.

Famously, in 2009, Pope Benedict XVI took a stark view of the liberal approach, telling reporters in Cameroon that “you can’t resolve” the problem of AIDS “with the distribution of condoms — on the contrary, it increases the problem.” The pope may have overstated his scientific case, but empirical evidence bears out his point, at least in part: As Harvard HIV researcher Edward Green wrote a few days after Pope Benedict’s statement (in a piece entitled “The Pope May Be Right,” the evidence suggests that condom distribution has not been an effective weapon against the pandemic, while behavioral change and, now, widespread provision of ARVs and MTCT prevention are. This battle still has not been won, though — Western aid workers continue to push higher-tech prophylactics, such as gels, which still fail miserably, as another study released just this week found.

But thanks to Western investment, more and more HIV-positive mothers are getting tests and drugs (both around birth and long-term) every year. In 2011, for instance, PEPFAR provided HIV tests to almost 10 million pregnant women, and provided preventive ARVs to 660,000 of them, dramatically reducing the odds of their babies’ being born with HIV. The nature of PEPFAR has changed a lot in recent years, and funding has not been increased at the rate administrators and activists have demanded (for which they have excoriated President Obama), but it’s a huge program that is still growing, and still saving lives at an unprecedented rate.

The programs President Bush initiated have probably been among the most successful humanitarian interventions in human history. Their significance may someday rank with the elimination of smallpox and polio among global-health triumphs, especially given the even greater challenges posed by HIV/AIDS. The Mississippi miracle could be a great step forward in the war on the world’s worst disease, but it would mean much less without the strides already taken.

— Patrick Brennan is a William F. Buckley Fellow at the National Review Institute.