Politics & Policy

The War on HIV

One of the great global-health triumphs

This week, the world was rocked by the news that an infant born in Mississippi with HIV has apparently been cured: The child tested positive for the disease several times in the first month after her birth, while she was receiving aggressive antiretroviral (ARV) treatment, but now, at the age of 23 months, she shows no sign of HIV.

This development points to a hopeful way forward for infants who contract HIV during gestation or at birth, but almost all of them live not in Mississippi, but in places like Mali and Namibia. Yet thanks to the United States government and private benefactors, prompted by President George W. Bush, many of those children and their mothers do have access to some HIV/AIDS treatment programs.

Just a decade ago, before President Bush inaugurated the President’s Emergency Plan for AIDS Relief (PEPFAR), it was considered impractical and unaffordable to provide the world’s poor with HIV drugs. But because the U.S. has implemented PEPFAR so widely, driving down the cost of the drugs dramatically, whatever treatments come out of the Mississippi case should now be feasible in areas like southern Africa, where the HIV pandemic still rages.

Essentially, a pregnant woman who is diagnosed as being HIV-positive is treated with especially high doses of ARVs, weakening the presence of the virus in her system and making her less likely to transmit it to her child via bodily fluids. Because of this treatment, mother-to-child transmission (MTCT) is now very rare in wealthy nations — only 100 to 200 American children per year are born with the virus.

In the Mississippi case, because many risk factors were present, the doctor decided to begin treating the child with HIV drugs just 31 hours after birth. This appears to have to knocked out the virus for good (even though the mother took the baby out of the doctors’ care after about twelve months). It seems likely that this will become a plausible treatment in wealthy countries in the rare case when MTCT still occurs. The most obvious implication for the developed world, in fact, is that more accurate and quicker testing of babies born to HIV-positive mothers is needed, to detect whether the preventive measures have failed.

But such transmissions remain heartbreakingly common in the developing world — globally, hundreds of thousands of babies every year are born infected with HIV, and some who escape pre-natal transmission acquire the virus soon afterward via breast feeding by an infected mother. Many poor mothers still don’t know they are infected; even if they do, they don’t have regular access to ARVs during pregnancy, and don’t receive a regimen of drugs. Without that dosage of drugs around birth, the odds of passing on the virus are as high as one in two.

But many impoverished women in Africa and elsewhere do receive some pharmaceutical treatment, and these programs are expanding rapidly, thanks to Western generosity. If it weren’t for the programs already implemented and the progress made, the discovery in Mississippi would be as meaningless to the vast majority of AIDS victims as ARVs were before President Bush took action.

For years, the twin totems of sexual tolerance and cost effectiveness meant that the West’s approach to the HIV/AIDS pandemic was to hand out condoms, withhold judgment about risky behavior, and watch Africans die.

That began to change when PEPFAR began investing billions of dollars in treatment programs around the world, but concentrated in southern Africa. Actual treatment for HIV/AIDS had been considered completely unaffordable in the developing world. But the U.S. government went to the multinational pharmaceutical firms that Western liberals had been demonizing for years, and offered to begin buying billions of dollars’ worth of drugs, for millions of new patients, in exchange for dramatically lower drug prices in African markets and quicker availability of generics. Unsurprisingly, the corporations agreed. Simultaneously, the government of South Africa, which is home to about a quarter of the world’s HIV victims, finally admitted — under pressure from domestic activist groups — that AIDS drugs do in fact work. In doing so, the country’s largest party, the African National Congress, had to let go of an anti-colonialist strain of denialism about the causes and treatment of HIV, which the U.N. repeatedly offered president Thabo Mbeki platforms to espouse.

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. 

Patrick Brennan was a senior communications official at the Department of Health and Human Services during the Trump administration and is former opinion editor of National Review Online.


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