AIDS FIGHT FAILS WITHOUT PREVENTION

An estimated 12,000 people worldwide will contract HIV today. Ninety
percent of them, approximately 10,800 people, will not learn they are
infected until full-blown AIDS hits them -- in 2015. Until then,
those people will unintentionally spread the virus that lies silently
within each of them.

But on Dec. 1, the 19th annual World AIDS Day, political leaders and
international health officials will, once again, tell the world that
although the fight is far from over, progress is being made. The
fight is indeed far from over -- but don't believe the second half of
such statements.

It is heartening that more than 2 million HIV-positive people are on
lifesaving anti-retroviral drugs (ARVs), thanks to generous programs
from the United States, the European Union, the Global Fund, the
Gates and Clinton foundations, and others. Americans should take
pride in the fact that, with official aid of more than $13 billion
since 2003, the United States has led the world in a manner that
evokes generous programs of the past such as the Marshall Plan.

But real progress must be measured by the only criterion that
ultimately matters: Is the number of people who are HIV-positive declining?

The answer is a resounding no. The number of people infected each day
still far outpaces the number of people going on treatment each day.
Anthony Fauci, the famed director of the National Institute of
Allergy and Infectious Diseases at the National Institutes of Health,
has stated the case in dramatic terms. Speaking in July at an
international conference, Fauci said: "For every one person that you
put in therapy, six new people get infected. So we're losing that game."

He went on to say, "Clearly, prevention must be addressed in a very
forceful way."

As a strategy to defeat HIV-AIDS, focusing primarily on treatment
will never succeed; it can only keep (some of the) people already
infected alive, and then only as long as they take ARVs every day for
the rest of their lives. (If they stop taking ARVs, even for a few
days, their infection will probably become drug-resistant.)

The only way to reverse the spread of the human immunodeficiency
virus is to focus on prevention. If ever an ounce of prevention was
worth a pound of cure, this is the case, since HIV lives undetected
in people for about eight years before it explodes into full-blown
AIDS. Here's the problem: More than 90 percent of the world's
HIV-positive people do not know their status and unintentionally
spread the virus for those eight years -- to their wives, lovers,
people with whom they share dirty hypodermic needles, almost anyone.

With a vaccine apparently a decade or more away (another major
clinical trial failure was announced last month) and a safe
microbicide for women still eluding researchers, prevention needs
immediate emphasis and far, far more resources. But most of those
fighting HIV-AIDS -- dedicated, hardworking people -- are still
reluctant to admit that current prevention strategies are failing. A
sound prevention strategy would encompass education and counseling,
free condoms, female empowerment, more male circumcision, and abstinence.

But none of this will work without widespread testing -- highly
confidential but highly encouraged (which can now be done with
simple, cheap 15-minute tests). I have been criticized in the past by
some in the international health community for advocating testing, on
the grounds that it would violate people's privacy. This is, of
course, not my intent: Confidentiality must be respected.

And attention must be paid when Fauci speaks. Along with former
president Bill Clinton, he is one of the few who have publicly
advocated vastly increased testing as part of a strategy to stop the
spread of HIV. (Even in the United States, according to the Centers
for Disease Control and Prevention, at least one in four Americans
with HIV do not know they are infected.)

In no other medical epidemic in modern history has detection been
such a low priority. But because HIV is sexually transmitted, it
still carries stigmas in much of the world, including, until fairly
recently, the United States. Those with AIDS lose jobs, are thrown
out of their families, are denied medical help and are left to die
alone. These appalling but widespread reactions lie behind
long-standing international guidelines that testing should be voluntary.

Here is my challenge to the international health community: This
year, tell the truth on World AIDS Day. Admit that we are still
losing. Advocate strategies that emphasize prevention and detection,
based on the successful "opt-out" testing systems being tried in
Botswana, Lesotho and Malawi.

If current policies are not changed, we will face uncontrollable
growth in the costs of treatment of the victims of a disease that
should be, as Bill Clinton has said, completely preventable.

Richard Holbrooke is president of the Global Business Coalition on
HIV/AIDS, Tuberculosis and Malaria. He wrote this article for The
Washington Post.