Pubdate: Fri, 12 Oct 2007
Source: Times Union (Albany, NY)
Copyright: 2007 Capital Newspapers Division of The Hearst Corporation
Contact: http://www.timesunion.com/forms/emaileditor.asp
Website: http://www.timesunion.com/
Details: http://www.mapinc.org/media/452
Author: Richard Holbrooke
Note: Richard Holbrooke is president of the Global Business Coalition 
on HIV/AIDS, Tuberculosis and Malaria. He wrote this article for The 
Washington Post.

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.
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