Prospects for AIDS prevention

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    With the future of HIV vaccines unclear, the pursuit of alternate strategies to curb the spread of AIDS is welcome.

    What are some options to halt the onslaught of AIDS in lieu of a vaccine? A recent article in the Financial Times reports that the World Bank is considering supporting a new approach to this problem: paying individuals to protect themselves.(see news story page 593). The plan would be a three-year trial in Tanzania in which participants are counseled on the prevention of sexually transmitted disease and are paid for periodically testing free of infection. A control arm would consist of individuals who receive only counseling.

    A payment plan may prove better at preventing HIV infection than counseling—which, alone, has been largely ineffectual—but the approach will require careful evaluation.

    Owing to the high cost of HIV tests, infection by other sexually transmitted pathogens, such as Neisseria gonorrhoeae, would be monitored. But if the incidence, transmission rates and detection accuracy of the sentinel pathogens are not equivalent to those of HIV, would the screening appropriately reflect the impact of the trial on HIV infection? Moreover, if individuals enroll in the hopes of receiving payments, the attrition rates for the two arms might differ dramatically, affecting the power of the study. And lengthy follow-up might be necessary to assess whether low-risk behavior is maintained in the long term or abandoned once payments stop.

    In the US, the government is debating a different response to the global AIDS epidemic—whether or not to reauthorize the President's Emergency Plan for AIDS Relief (PEPFAR).

    PEPFAR has provided $15 billion over the past five years for AIDS treatment and prevention, making the US the largest contributor to AIDS relief in the world. Since its inception, PEPFAR has supplied antiretroviral treatment to almost 1.5 million HIV-infected individuals and aims, over the course of 10 years, to treat 2.5 million people, prevent 12 million new infections and care for 12 million persons affected by the AIDS epidemic. The bill's mandate expires this September, and the President has requested an additional $30 billion for the next five years of the program.

    In the past, the plan has garnered criticism because one-third of the funds for prevention are allocated to programs that promote abstinence—another approach that, by itself, has not halted the spread of HIV. In April, the US House of Representatives approved a bill that reauthorizes PEPFAR, increases its funding to $50 billion and sensibly removes the one-third stipulation on the use of prevention monies, instead requiring more “balanced funding” of prevention measures. Reauthorization of the plan also expands its purview to support programs that help combat malaria and tuberculosis and improve health and education in general—efforts that are anticipated to indirectly affect the spread of AIDS.

    But the bill must be approved by the US Senate, and seven senators seem intent on blocking its passage. At issue is the expansion of PEPFAR in both cost and scope. In a letter to the Senate Republican leader, the dissenting senators object to the funding increase, calling it “irresponsible,” and claim it will benefit unduly program officers and consultants. To prevent this, they wish to restore a mandate that at least 55% of PEPFAR funds are used for treatment of HIV-infected individuals. The mandate was applied during the first five years of PEPFAR but removed in the reauthorization bill to give countries greater flexibility in spending decisions.

    The senators reject the expansion of PEPFAR to projects addressing other health concerns, claiming that this “mission creep” turns PEPFAR into a development program and dilutes the focus on HIV/AIDS. And they attack the aid increase allocated to the UN to support the Global Fund to Fight HIV/AIDS, as well as the World Health Organization, which they state promotes “dubious health initiatives,” such as needle exchange programs—and, apparently worse, HIV vaccine and microbicide research. The senators' objection to the bill may delay reauthorization of PEPFAR until 2009.

    One critic accuses the senators of supporting human suffering through a lack of generosity and a conservative ideology that rejects practical HIV prevention measures. Tom Coburn, the senator leading the stand-off, insists that his intent is to ensure treatment of HIV/AIDS. But the senators' letter undermines this contention—its criticism is squarely levied at the increased funding and breadth of PEPFAR, and its potential support of activities perceived by the senators to be morally suspect.

    Coburn argues that “treatment is prevention,” yet treatment alone is not curbing the spread of HIV, and prevention strategies of all forms are crucial to AIDS relief. And if distributing needles, condoms and microbicides and improving the general health conditions of populations at risk are, in combination with treatment, the best bets in the war on AIDS in the absence of a vaccine, then such approaches—and PEPFAR's funds—should not be held hostage to the moral qualms of a few on the US Senate floor.

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