Stephen Lewis believes in drug treatment for victims, but only prevention can stop the scourge
The document was like a Rorschach ink blot test: two people looked at the same evidence and drew opposite conclusions.
This past summer, the World Health Organization released an interim report on the “3 by 5” initiative, the world’s flagship anti-AIDS program. The multi-billion-dollar plan was meant to get three million HIV-infected people in the developing world onto antiretroviral (ARV) drug treatment by the end of 2005. In its update, the WHO announced that, while one million people were receiving treatment, the program is so far behind the schedule that the target won’t be reached this year. The WHO also said that, although the world had pledged US$27 billion over the next three years to fight AIDS, another $18 billion was needed. Not to worry, though. Even though it missed the 2005 target, the WHO insisted it remained committed to an even more ambitious and expensive longterm goal: getting anti-AIDS drugs to every infected person in the developing world by 2010.
For Stephen Lewis, United Nations special envoy for HIV/AIDS in Africa, the WHO report was proof that the strategy of beating
AIDS in the developing world by concentrating on treatment is the right one. “The 3 by 5 initiative seems to me to be entirely vindicated,” Lewis said in a speech in Nairobi, Kenya, as the WHO report was released. “Mind you, I can even now hear the curmudgeonly bleats of the detractors, whining that we will fall short of the target. Tell that to the million people who are now on treatment and would otherwise be dead.” He called for more hard work to meet the goals and predicted the 3 by 5 initiative “will one day be seen as one of the UN’s finest hours.”
The day after Lewis spoke, the head curmudgeon was hard at work in his sparse, second-floor office in a Toronto hospital annex. Dr. Prabhat Jha is Lewis’s opposite, and not just ideologically: whereas Lewis tends to sermonize with an almost Biblical fury, Jha is soft-spoken, cautious, scientific and clinical. As the Canada Research Chair of Health and Development at the University of Toronto, and director of the Centre for Global Health Research at St. Michael’s Hospital, he has spent the last few years bleating, loudly, that the UN and the international community are getting it all wrong on AIDS. He sees the WHO
report as further proof that the overwhelming focus on ARV drug treatment, and the limited donor interest in humdrum disease prevention, is “well meaning but ill-founded.”
“Treatment is a moral imperative,” says Jha, “but to break the back of the epidemic, we’ve really put a lot on one horse, and we’re starting to see the problems with that.” The problems, as he sees them, are a simple matter of arithmetic: the number of new infections is outpacing efforts to treat them. Last month, UNAIDS announced that 2005 established a new record for infections: five million people became HIV-positive this year, including more than three million new cases in Africa. Even if the 3 by 5 initiative had reached its target, it would still be working far behind the pace of the virus.
For Jha, this is madness: instead of focusing on preventing people from getting the disease—a relatively low-cost, low-tech, proven approach—the international community is concentrating on treating them once they get it—at great cost, and with seemingly little prospect of outpacing the epidemic.
Consider the example of Botswana, which Jha says has “the best program for ARVs in the world.” The country is peaceful, relatively prosperous and well-governed, and is receiving extensive international help in ramping up its HIV drug treatment program as part of the 3 by 5 campaign. And yet even here, the tide of new infections is rising faster than the volume of people receiving treatment. “They’ve got about 350,000 people who are HIV-positive, and they’ve only managed to enrol about 40,000 to date on ARVs, and expect to get to perhaps 100,000 in five years,” Jha said. “But in that time period, they will have something like 200,000 new infections.” In much of the rest of the developing world, the calculus is even more dire.
“That’s not to say we should throw ARVs away, but we’ve got to say, what do we need to make this epidemic smaller and more manageable?” Jha’s answer: a “massive scale-up in prevention. To prevent the nightmare scenario of 100 million infected in a year, we’ve got to put our emphasis on stopping new infections. That’s Public Health 101.”
Jha’s career has been all Public Health 101.
Raised in Winnipeg, he’s got a medical degree from the University of Manitoba and a doctorate in epidemiology and public health from Oxford. He’s worked for both the World Bank, on HIV and malaria control projects, and the WHO, the organization whose AIDS strategy he now criticizes. He is currently heading up the world’s largest health study, a survey of the lifestyles of 15 million Indians. “It’s all focused on measurement of how people live,” says Jha, “so as to understand how they die. And from that, you can get appropriate public health strategies.”
Use of condoms in brothels has slashed Thailand’s HIV infection rate
It’s this background that has led Jha to argue that the way to ending the AIDS epidemic lies in preventing people from getting the infection in the first place. The key? Education about condoms—with a focus on prostitutes. “The most compelling evidence is, there is no major heterosexual epidemic in places where you’ve got protected sex work.” That, says Jha, is because, “HIV is actually very hard to transmit. It’s got perhaps a one in 1,000 chance of transmitting per act.” As a result, “if epidemics grow, it’s only because there are groups that are such high risk because they have a lot of other infections or they have rapid change in partners.”
This approach’s leading success story? Thailand, where the HIV infection rate has plummeted. In 1991, Thailand had 143,000 new HIV cases. By 2003, it had just 21,000 new cases, according to WHO and UNAIDS. “They had this very simple strategy: intervene, monitor, enforce 100 per cent condom use in brothels,” says Jha. “They turned what could have been a very rapid epidemic around.” Concentrating on the sex industry does not mean banning prostitution. It doesn’t mean preaching abstinence, or stigmatizing people in the sex industry either. It means getting them to understand how HIV is transmitted, and why they must use condoms. That means giving a certain kind of recognition to sex work, by directing funds and attention to educating sex workers—not always an easy sell for donors. “Pardy for political reasons, official agencies have shied away from talking about paid sex, sex work, etc.,” says Jha. “The Bush administration is notorious in doing so.”
A big infrastructure is not required, Jha says. “You need retired sex workers to reach their own. They have networks, they’re able to relate to their own, and educate them about
condoms, make sure they’re available, make sure they have good access to general health services.” Where it has been tried, the model has been “exceedingly effective”—in Cambodia, parts of Africa, and some regions of India. Jha calls India, the world’s second most populous country, “a disaster pending” unless it takes the right HIV prevention measures.
Jha cites Toronto’s red-light district as an example of how a city can have widespread prostitution and yet not have an AIDS epidemic. The sex industry “changed overnight— it became a condom-provided market. You simply cannot procure unprotected sex on the streets in Toronto or Amsterdam. In developing countries you still can.” Once again, it’s Public Health 101: “Where countries have recognized that—in Cambodia, in Thailand—and they’ve done intervention programs,” he says, the epidemic has been stopped in its tracks.
Instead of 3 by 5, Jha is pushing what he calls “8 by 10”: preventing eight million new infections by 2010. That would cut the global infection rate in half, leaving fewer people in need of HIV drugs, and making it possible for treatment to catch up to the number of patients.
So why aren’t Jha’s ideas gaining more traction? There’s no disagreement in principle on the benefits of prevention. UNAIDS’ 2004 “Report on the Global AIDS Epidemic” notes that “comprehensive prevention could avert 29 million of the 45 million new infections projected to occur this decade. Without sharply reducing the number of new HIV infections, expanded access to treatment becomes unsustainable. Providers of antiretroviral treatment will be swamped by demand.” Lewis and others running the world’s antiAIDS effort are obviously interested in reducing the number of new cases of the disease. But their overwhelming bias continues to favour concentrating most of the money and effort on treatment—and arguing that the more ARV drugs are available, the more people will enroll in testing and prevention.
Tf we don’t deliver soon on AIDS, how will we win back public support?’
The theory goes something like this: unless people know that treatment is available for AIDS, they will refuse to be tested, or involve themselves in AIDS prevention programs. The WHO sees more treatment as essentially causing more prevention. As Dr. Jim Yong Kim, the WHO’s head of HIV-AIDS, wrote recently in the Washington Post, “before treatment became available in the developing world, governments had little reason to invest in HIV testing, and individuals had no reason to know their status. Today, however, access to treatment is driving new interest in HIV prevention and testing among governments and individuals.”
That’s Lewis’s line as well. It “becomes irrefutably clear that treatment has been a boon to prevention,” said Lewis in Nairobi. “I can recall all the caterwauling about the neglect of prevention as the world began to focus on treatment. But the detractors were wrong again.” Lewis cited statistics from the WHO report, showing that in one village in Uganda, after ARV drugs were introduced, there was a 27-fold increase in counselling and testing— which he and the WHO see as the first step to both treatment and prevention. UNAIDS 2005 report on the epidemic insists that “evidence and experience show that rapidly increasing the availability of antiretroviral therapy leads to greater uptake of HIV testing.”
Jha’s response? “I would gently say that’s wishful thinking.” He says the statistics show a very different story than the one painted by Lewis’s one-village anecdote: wider availability of treatment, from the U.S. to Uganda, has
not sparked greater testing, more widespread prevention measures, or a reduction in the spread of the virus. If anything, Jha argues, treatment can make people engage in riskier behaviour because they begin to believe that even if they contract HIV, it can be cured. And there’s no disputing that the number of HIV infections continues to rise, even as treatment is ramping up.
“I’m a huge admirer of him, and he’s one of the most passionate, articulate people,” Jha says of Lewis. “Where we would disagree is he thinks that ARVs are going to mobilize all of these other efforts. We’ve seen enough actual experience where that hasn’t happened.”
UNAIDS says that the cost of its anti-HIV strategy in the developing world will rise to US$22.1 billion a year by 2008. To put that in perspective, this past summer British Prime Minister Tony Blair managed to wring a promise out of the G8 to double aid to Africa by 2010, increasing it by $25 billion. That aid is supposed to support a host of health, education and infrastructure projects across the continent— yet the HIV treatment strategy could, by itself, eat up almost all of the new aid money.
Again, the Rorschach test. Stephen Lewis and Prabhat Jha both see this as a potential turning point in the history of the epidemic, while disagreeing sharply on the direction of that turn. For Lewis, the call is for greater generosity, not a change in strategy. “The idea of doubling aid for Africa by 2010, which would represent another $25 billion per year, is clearly inadequate, some might say paltry,” he said in his Nairobi speech. For Jha, the speed at which the cost of treating the epidemic is outpacing even the G8’s massive new foreign aid promises is a warning that we’re on the wrong path—and a call to change course, before donor-fatigue sets in.
“We’ve got a historic opportunity: when did rock stars and politicians suddenly start having this common agenda?”asks Jha.“And if the world doesn’t deliver in a few years on AIDS, how are we going to get the public support back? We’ll say, ‘sorry, we blew it—we want even more of your tax money’? What would a taxpayer say? They’ll say:
‘get lost.’ There is that risk that we shouldn’t underestimate.” M
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