U.S. PLAN ON AIDS NEEDS A CHANGE

The 16th International AIDS Conference in Toronto was held August
13-18. I was privileged to attend this, the largest gathering of HIV
scientists and activists in the 25 years since AIDS was first
described. I still remember, as a freshman medical student, the first
case reports of healthy young men developing rare and fatal
infections. Fear has given way to knowledge. No other disease has
yielded so many discoveries in so short a time.

The "cocktail" of HIV drugs became widely available 10 years ago in
the developed world. The death sentence of AIDS has been transformed
into a manageable chronic condition, as reflected in my own HIV
practice. But, 10 percent of all people in the world with HIV, mostly
Westerners, receive 90 percent of the treatment. In the developing
world, lifesaving drugs were rarely available until three to four
years ago. Since then, close to half a million patients annually have
started treatment, with a goal of 10 million. But, almost 5 million
new HIV infections occur globally each year, and new HIV cases in the
USA remain steady.

It will take $20 billion a year to deal with global AIDS. Global
resources fall into three main categories: President's Emergency Plan
for AIDS Relief (President Bush's PEPFAR), The Global Fund (other
nations and various donors), and private charities (such as the Gates
Foundation). These groups provide about $5 billion a year, roughly
equivalent to three weeks of U.S. expenditures in Iraq. So, resources
are clearly available, even if political will is lacking.

Some say that HIV prevention is easy as ABC: Abstinence, Be faithful,
and Condoms. It's so catchy that President Bush's PEPFAR mandates
one-third of prevention dollars to go to abstinence-only programs.
Data show that abstinence-only does delay the age of sexual activity,
but in the long run increases HIV risk compared to programs that also
provide a back-up plan. Some of the fastest rising rates of HIV (such
as in India) occur in monogamous, faithful married women who were
abstinent before marriage. It takes two (not) to tango for abstinence
and faithfulness to succeed. PEPFAR ignores this.

A huge theme at this conference was women, girls, and HIV. HIV is
tied in with poverty, lack of education, and lack of power.
Female-based prevention tools are needed now. The Gates Foundation is
supporting research in Africa on microbicides for women, gels with
anti-viral agents to prevent the spread of HIV. Abstinence-only
ignores this option.

The other epidemic, especially in Russia, is HIV spread through
injection drug use. Plenty of that in Oregon, too! Increased
criminalization of drug use is actually associated with increased HIV
rates. Transmission is reduced with rehabilitation and needle
exchange programs.

The scientific debate is over, needle exchange programs work.
Nevertheless, our leaders refuse to support this, and still
erroneously believe that providing safe injection equipment increases drug use.

Finally, data show that free access to HIV care may be the most
important determinant of treatment success and prevention. Widespread
HIV treatment reduces viral load so that transmission is reduced.
Generic drugs can bring treatment cost down to 50 cents a day!
President Bush has fought the use of generics and universal access.

The USA has among the highest HIV rates in the developed world, an
appalling fact. American policy calls for abstinence-only, no needle
exchange, no universal access to care, faith-based restrictions on
prevention, and drug company profits over human lives. This is not
some liberal, partisan rhetoric. It is a plea for common sense and
pragmatism to use proven tools to fight AIDS, save lives, and save
money. Leadership from above is lacking, so please do what you can
from the ground up: Contact your legislators, school board, do
something. Clinging to ideology over evidence can kill.