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Keep it Together at AIDS 2010: Moving Beyond the Pitfalls of False Dichotomies

Let’s face it, we’re in one of the worst economic crises we’ve seen in decades, and HIV funding has flat-lined. In editorials and the blogoshere, we are seeing the old debates over investing precious resources once again rear their ugly, divisive heads—HIV prevention versus treatment, HIV versus other global health concerns, one type of HIV prevention versus another.

But, as former United States President Bill Clinton said in his speech Monday, “We’ve been there before,” so I’m challenging us to look beyond these dichotomies. In a climate of limited funding, we will be limited in what we can do, but that means we have to get creative and get smart. I’d like to share some of the evidence-based solutions I’m hearing about at AIDS 2010 that take us beyond the false dichotomies.

Treatment is Prevention

Yesterday, I learned about models coming out of South Africa that analyze the cost of putting people living with HIV on antiretroviral therapy (ARVs) and the cost savings of preventing new infections by lowering people’s infectivity with drug treatment. This data suggests that in the long run, it would be more cost-effective to offer ARVs to all people living with HIV, regardless of their CD4 status because the costs allayed from preventing new infections would outweigh the cost of universal treatment by 2022. This holds true under fairly conservative, realistic assumptions, and estimates of drug costs that are a bit higher than what is currently available at negotiated prices. In fact, the models show that even a less ambitious approach of offering ARVs to all people living with HIV who have a CD4 count less than 350 cells—as new World Health Organization guidelines recommend—would pay for itself by 2013.

HIV Funding Can Support the Larger Global Health Agenda

I attended a presentation about whether HIV programming is crowding out programs on other important global health needs. The data—taken from different studies with various approaches—suggested that HIV programs were either neutral in their effects on other programs or, in some cases, were shown to improve the quality and delivery of health care services in non-HIV programs. For example, one study looked at programs focused on stopping preventable deaths in children younger than five. This study found that these programs had shown dramatic progress in the PEPFAR-focus countries since PEPFAR’s inception when compared to non-PEPFAR-focus countries in Africa. The presenters also highlighted a study from Rwanda that found that staff at HIV clinics was more efficient in providing some non-HIV services when comparing clinic output and the number of staff.

Even so, we must keep in mind the findings of a recent Lancet article, which suggest that the governments of some developing countries have reallocated parts of their health budgets to other government sectors because they know they can fill the gaps with funding from donor countries, particularly the influx of HIV/AIDS funds. While there are many pressing needs in resource-poor settings, governments should abide by their commitments to fund health care, especially those governments that signed the 2000 Abuja Declaration and committed to spending 15% of their budgets on health, including in part on HIV programs. 

Biomedical HIV Prevention Approaches Depend on Behavior Change

Finally, I want to touch on a really important message I’m hearing here at AIDS 2010. It is this: biomedical interventions require behavior change. We cannot abandon our focus on what we know works at preventing new HIV infections: practicing safer sex, including using female and male condoms; knowing and sharing your HIV status; taking ARVs; using clean needles; and stopping violence.

Even as we focus on the preventive nature of treatment, the partial protections of adult male circumcision, and the possibilities of microbicides, we have to recognize that these HIV prevention strategies still require people to follow treatment guidelines, to use condoms even after the surgery, and use microbicides consistently and preferably in combination with a second protection method. Barring the development of an HIV vaccine, behavior change will always be a necessary component of HIV programs.