Opportunity Knocks Twice: New Tools Could Control the HIV Epidemic

The American people have led the fight against global HIV for nearly a decade. Africans will know who we are as a people and what we stand for if we continue to stand with them.
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This June marked the 30th year since the first case of what became HIV was reported. An infection that was a death sentence is now treated around the world as a chronic disease. Just ten years ago, experts argued that treating people in Africa was not possible because they were too poor and uneducated. That slander was compounded by myths that Africans were too promiscuous and could not control their instincts. In fact, Africans have fewer lifetime partners than Americans.

In 2003, President Bush rejected the morally indefensible position of ignoring scientific advances and allowing the then-estimated 27 million HIV-positive Africans to die. He launched the President's Emergency Plan for AIDS Relief (PEPFAR), the largest international initiative in history to combat a single disease. Large, bipartisan Congressional majorities provided the money to both bilateral programs and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Today, more than 5.2 million people are receiving life-saving antiretroviral therapy in low- and middle-income countries. The compassion and generosity of the American people supports 3.2 million of them, nearly all in Sub-Saharan Africa.

PEPFAR succeeded because it trusted the innovative, talented and dedicated people of Africa to solve the difficult issues of how to provide effective chronic care with limited personnel and poor infrastructure. Together, Africans and Americans seized the opportunity that science provided.

Opportunity is knocking at the door a second time. PEPFAR was not just about treatment. It also supported a massive expansion of programs to prevent new HIV infections and slow the rapidly expanding pool of people needing treatment. Again, Africans responded to the challenge: more than 33 countries have reduced the rate of infection by more than 25 percent -- 22 in Sub-Saharan Africa. In countries where extensive evaluations have been done, there has been more than a 50 percent decline in new infections among difficult populations of young adults. But until recently, we have been relying on behavior change and the use of condoms, which can be difficult to maintain.

Science has significantly expanded the options. Studies have shown that circumcising males can reduce infections in men by 60 percent, a protective effect that is increasing over time. The drugs used to treat HIV can also prevent the spread of HIV. The amount of virus a person carries is directly related to the likelihood that it will be spread during sex. Most HIV positive people live for many years before they require treatment for their own clinical benefit. Because therapy reduces viral levels, researchers evaluated the impact of treatment at the time of HIV diagnosis compared to waiting until it was needed. Transmission to regular, uninfected partners was reduced by a whopping 96 percent with earlier treatment.

People who are not infected with HIV can also benefit by taking drugs to prevent contracting the virus in the first place. In a recent study, transmission was reduced by more than 40 percent in HIV-negative gay men assigned to take daily medication -- more than 90 percent among those who regularly took it. A clinical trial among women did not have such compelling results. Because of the way the trial was conducted, it is not possible to determine if the lack of effectiveness was due to a biological cause or to poor adherence to the drug regimen. Research underway should provide clarity.

But there is already good news for women. When the pills used for treatment are reformulated as a gel and applied before and after sex, infection rates in women were reduced by more than 40 percent -- the effect significantly increased when the product was used as intended.

We are entering a new era in HIV prevention. PEPFAR promoted a "combination prevention" strategy from the beginning. But the tools were limited. Scientific advances could give individuals the ability to determine the prevention intervention that works best for them. Preliminary mathematical models suggest that combining a full range of prevention interventions is additive -- and could drive the epidemic down to a manageable level so that when a vaccine is available, it could mop up what remains.

Achieving that vision will not be easy. It requires resources at a time when money is scarce. But few programs domestic or international can draw a straight line from dollars invested to lives saved. Implementing programs will be difficult. But the problems are not remarkably different than those the skeptics claimed made treatment impossible.

If we seize the opportunity science has provided, history could be made again and the HIV epidemic could be driven into the ground. The American people have led the fight against global HIV for nearly a decade. Africans will know who we are as a people and what we stand for if we continue to stand with them. Opportunity rarely knocks a third time.

Ambassador Dybul is a Distinguished Scholar at the O'Neill Institute of Global and National Health Law, Georgetown University and is the inaugural Global Health Fellow at the George W. Bush Institute. He was US Global AIDS Coordinator from 2006 to 2009.

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