This week, the United Nations General Assembly meets to discuss progress against the HIV/AIDS epidemic amid news that antiretroviral drugs can drastically reduce HIV transmission from infected to non-infected partners. The U.N.’s AIDS agency, UNAIDS, has already called this news a “game changer” and at this week’s meeting will doubtless call for massive infusions of donor funding in order to implement this treatment-as-prevention approach.
Nearly as certain is that little will be said about investing in programs to encourage the kind of fundamental behavior change, particularly faithfulness between sexual partners, that has already saved millions of lives worldwide. Serious investment in such programs would cost a tiny fraction of the vast sums required for HIV treatment. Yet there is a serious lack of political will to invest in simple, low-cost programs which address the real drivers of the HIV epidemic, such as multiple sexual partners.
We have known for decades that risky sexual behaviors can be changed at a population level, and that when this happens, HIV declines rapidly. Uganda saw HIV infections fall by two-thirds in the 1980s and 1990s in response to simple, locally generated messages about the danger of multiple sexual partnerships. Uganda’s approach cost a mere 25 cents per person, per year. Kenya, Zimbabwe, and a number of other African countries have seen similar declines in HIV accompanied by trends towards less risky sexual behavior, especially greater faithfulness among sexual partners.
In contrast, treatment-as-prevention is an expensive and technologically-driven solution with serious barriers of cost, implementation, and acceptability. Requiring that still healthy individuals start a regimen of toxic drugs as soon as they become infected, 7 to 10 years before they develop the symptoms of AIDS, is not without risks for those individuals, and in fact 1 in 5 people who start treatment drop out within a year. Some researchers have suggested that the increased viral resistance created by having people on treatment longer could lead to increased number of new infections.
Behavioral programs do not require large amounts of resources, and we submit that the main challenge is not coming up with more money for prevention but rather orienting funds toward the right approaches. We fully support access to treatment for all persons living with HIV, and note the tragedy that as a global community we are already failing to provide treatment to 9 million men, women, and children who need HIV treatment today. The greater tragedy may be that we are also failing to invest in the simple and effective behavioral prevention which could prevent millions of infections, if the global community would only muster the same enthusiasm for behavior change — or for positive reinforcement of healthy behaviors — that it is showing for drug-based solutions.
— Edward Green is former director of the New Paradigm Fund. Allison Herling Ruark is pursuing a Ph.D. at the Johns Hopkins Bloomberg School of Public Health. Norman Hearst is a professor at UC–San Francisco.