Curtailing the HIV Epidemic: The Power of Prevention

Keynote Address

June 22, 2001

Michael H. Merson, M.D.

Dean of Public Health, Yale University

I want to first thank the Henry J. Kaiser Family Foundation, Ford Foundation and the Bill and Melinda Gates Foundation for inviting me to present the keynote address at this Leadership Forum.  It is a particularly challenging task after we have had the privilege of hearing from His Excellency, President Yoweri Museveni, whose actions have spoken louder than any words I could offer. 

How well I remember that day in May 1986, when his Minister of Health courageously stood up – he was the first to do so – and announced to the World Health Assembly in Geneva that his country was confronting a major AIDS epidemic.  He pleaded that other delegates also acknowledge that the epidemic was spreading in their countries so an international response could be mobilized.  If only others around the world had displayed this type of courage, perhaps we would not be here today.

Webster defines a keynote address as one that presents the “essential issues of interest”.  In the next twenty minutes or so, I will present the case for HIV prevention, by reviewing the context in which prevention must succeed, the essential elements of a successful HIV prevention strategy, and the actions required for prevention to work effectively.

Let me preface by saying that I will not enter into what has become a most unfortunate and needless debate about the merits of prevention as opposed to care.  Both are crucial and must be greatly scaled up.  Prevention and care are complimentary and synergistic, and efforts to prioritize one at the expense of the other are unethical, a denial of a fundamental human right, and just plain bad public health.  More on this later.

I begin with the context.  We are now in the twentieth year of the most devastating pandemic in the history of modern civilization.  The Bubonic Plague of the Middle Ages killed as many people, but its spread across the globe was not nearly as rapid and its acute impact thus not nearly as profound. 

Since 1990, the total number of HIV infections increased tenfold - from 6 million to nearly 60 million – and it is nowhere near its peak.  We all know how severely Africa has been affected. Across the African continent, there are now 25 million persons living with HIV and AIDS, the health care system has become an AIDS care system, and more than ten million orphans are looking for a home.  In the countries of Southern Africa, 20% of the adult population are infected, and in less than a decade, life expectancy has dropped 15 to 20 years.

We have seen the pandemic gradually extend throughout Asia, from Thailand and the countries in the Golden Triangle, to China, where the extent of its spread is not known, to India, which has, or soon will have, more infections than any other country. 

In the Ukraine, Russia and the rest of Eastern Europe, where the social conditions could not be more ideal for the spread of the virus, the pandemic is now expanding at an exponential rate. 

In the Western Hemisphere, we have seen the second highest rates of HIV infection globally in the Caribbean, while in Central and South America the pandemic continues to surface in diverse and vulnerable populations.  In the United States, we are told that the epidemic has stabilized, but at an appalling rate of 40,000 new infections per year.  The majority of these infections occur in populations of color, while rates of infection are increasing in men who have sex with men, as they are in Western Europe, due to complacency about prevention and the availability of antiretroviral therapy.

In some countries, prevention programs have achieved considerable success –I will expand on this in a minute - but for the most part, the response to the pandemic has been delayed, inappropriate or insufficient.  As an infection transmitted primarily by sex or by illicit drug use, and associated with stigmatized and marginalized groups, HIV has all too often engendered moralistic or repressive responses, rather than sound public health actions.  In addition, the response of the international community has been, at best, indifferent, and at worst, disgraceful. Just as one example, development assistance for AIDS activities in the least developed and other low income countries reached a maximum of a paltry 144 million dollars a year during most of the 1990s, and was a mere 70 million dollars a year in Africa between 1996 and 1998.

The good news is that the context is changing, and as Peter Piot said at the recent World Health Assembly, “we are witnessing a ‘seachange’ ” – finally, I might add – “in the international response to the pandemic”.  This can be seen in the World Bank’s heightened commitment, particularly for Africa, where it is projected by next year to approve 1 billion new dollars in credits to scale up prevention and care efforts in 25 countries.  The major international foundations, such as those hosting this meeting, have also dramatically increased their support to HIV/AIDS activities. 

Some of this ‘seachange’ is due to increased awareness about the pandemic’s severity, much of it a result of the convening of the Thirteenth International AIDS Conference in Durban last summer.  Some of it is related to the new and exciting developments in the search for an HIV vaccine and the serious efforts underway, after years of little more than neglect, to find a safe and effective microbicide. 

But probably the greatest impetus for this turning point in the international response has been global concern about equity in access to antiretroviral drugs in low and middle-income countries. This concern originated with the use of these drugs, given to pregnant women near or at delivery, to successfully interrupt maternal to child transmission. Greater equity in access to antiretroviral drugs was made a reality by the substantial reduction in their price in these countries during the past six months, and the remarkable success reported by Brazil in reducing AIDS-related mortality, hospitalizations and opportunistic infections, as well as the overall costs of AIDS care, as a result of their widespread use. 

For the first time in the pandemic’s history, comprehensive AIDS care is now a reality, for everyone.

If this is the context in which HIV prevention now operates, what should be the main elements of an effective prevention strategy? 

Two background papers for this conference – one senior-authored by Dr. Allan Rosenfield and the other by Dr. Daniel Low Beer – have documented the compelling evidence of the success of our behavioral prevention interventions, whether directed towards individuals, couples, families, communities or society at large, in reducing sexual transmission and transmission through injection drug use.  In fact, social and behavioral scientists have been able to provide more scientific evidence of the effectiveness of these interventions than exists for prevention of most other behavior-related diseases. 

In addition, a growing number of countries have proven the success of their prevention efforts through careful program evaluations and well-designed surveys.  There should be no doubt in our minds that these behavioral interventions can reverse a major epidemic, as we have seen in Uganda and Zambia; can contain an emerging epidemic, as we have observed in Thailand and Brazil; and can avoid an epidemic all together, as has been very well documented in Senegal.

It is not possible here to review the evidence for effective prevention in detail, but there are elements of successful prevention programs worth emphasizing.

First, they are tailored to the social and economic conditions and to the social and cultural norms of the populations that need to be reached.  Effective HIV prevention messages are based on knowledge and understanding of local attitudes, behaviors and practices.

Second, they present information that empowers those at risk to understand their risk and to know how to protect themselves from infection.  This means talking frankly about comprehensive sexual education and harm reduction, especially with youth.  In populations where sex during adolescence is the norm, abstinence-only messages are equivalent to teenage genocide.

Third, successful prevention programs involve those who are infected by the virus, as well as members of civil society, ranging from women’s groups, to gay men’s AIDS services organizations, to families caring for orphans.

Fourth, they take place within a supportive legal framework, which protects HIV infected persons and those vulnerable to infection from discrimination in all its ugly forms, assures them the right to liberty and security before the law, as well as the right to marry, found a family and have equal access to education and employment.  This entails the elimination of forced HIV testing and the repealing of laws that criminalize homosexuality and commercial sex work.

Fifth, successful prevention programs are multi-faceted and multi-sectoral – there is no single magic bullet.

Sixth, they are sustained over time, as populations at risk change.  Prevention must be reinvented over and over to keep reaching the next audience and to be heard and to be believed.

And last, and some would say most important, successful prevention requires strong political leadership that is committed to HIV prevention and mobilizes all government ministries, civil society and the private sector toward this common goal.

Two other important points about HIV prevention.  First, as documented in the background paper prepared by Dr. Elliott Marseille and others for this conference, HIV prevention strategies are highly cost-effective – including condom promotion, voluntary counseling and testing, treatment of sexually transmitted diseases and harm reduction interventions in injection drug users – and they have the greatest benefit when HIV prevalence is low and they are targeted to high risk groups.  Political leaders should not doubt their effectiveness, nor be concerned about their cost.

Second, in a number of ways, the increasing availability of antiretroviral drugs should benefit prevention efforts.  Persons who believe they may be infected, no longer fearing a death sentence, are more likely to seek voluntary counseling and testing. If they are found negative, this offers a prime opportunity to deliver prevention messages.  If they are found to be infected, the treatment setting provides an ideal time to repeatedly reinforce these messages, which is particularly important, since it has been shown that those receiving antiretroviral therapy can have demonstrable increases in high-risk behavior and sexually transmitted diseases.

The availability of antiretroviral therapy for pregnant mothers encourages them to come for testing as a means of preventing infection in their newborn.   Continuing this treatment in mothers after delivery will allow those who wish to more safely breast-feed, which is important for preventing diarrhea and malnutrition in their infants.

Also, at a societal level, the removal of the death sentence from AIDS will no doubt reduce the stigma around HIV infection, which should in turn decrease discrimination against HIV infected persons. 

Finally, it is likely that antiretroviral therapy, if provided to most of those in need, has the added prevention benefit of lessening the likelihood of sexual transmission by decreasing the body’s viral load.

Comprehensive care has other types of prevention benefits.  It keeps families together longer, so that children do not have to leave school, and parents do not have to stop working in the field or factory and can save money for the orphan years of their children.  Also, by keeping young adults alive longer, it can lessen the impact of the epidemic on a nation’s economic development and help to maintain national security.

For all these reasons, there should be no doubt that prevention and care are natural allies and paramount in our efforts to control the pandemic, and that efforts to pit one against another are morally indefensible and scientifically incorrect.

It is true that the safe and effective administration of antiretroviral drugs will require training of health care providers, strengthening of counseling and laboratory services, improvement of logistics systems, and small and large-scale operational research trials to determine the best treatment regimens and operational strategies for monitoring patients.  These efforts should always include prevention components, so that we can simultaneously strengthen the primary prevention infrastructure and discover novel and innovative ways to deliver our prevention strategies. 

I might add that one of the best ways to stimulate development of the care and prevention infrastructure is to have drugs and condoms to deliver. Everywhere a beginning can be made.

I conclude now with some thoughts on how we can take HIV prevention to the scale required to curtail the spread of the pandemic.

·        We need, first and foremost to apply, at dramatically increased levels, what we have learned over the past two decades about prevention.  Truth must overcome denial.  Urgency must replace complacency.  And just as we must overcome our prejudices and abandon our erroneous and unfounded assumptions about the inabilities of those living in low income countries to take antiretroviral drugs because of dosing schedules, treatment adherence or drug-resistant superviruses, we must drop our cynicism about the effectiveness of our behavioral interventions.  By careful monitoring and vigorous evaluation of programs, we can document their impact and identify their deficiencies so we can improve them as we move forward.

·        We need to greatly expand our research efforts to develop new prevention tools, particularly an HIV vaccine and microbicides.  More incentives and innovative mechanisms are needed to ensure that products that are developed are effective, affordable and accessible for those who need them the most.  We should not assume that their availability would remove the need for behavioral interventions.  On the contrary, experts tell us that at least for the foreseeable future, we are likely to have vaccines that provide only modest protection and reduction of transmission of the virus.

·        We need to take far more seriously the importance of reducing the social and economic vulnerability of those susceptible to HIV infection.  Creating a true power balance between women and men, and providing all women the freedom to exercise control over their own sexuality, as well as education and access to the cash economy, are good places to start.  Laws and customs that protect the rights of those infected with HIV should also be vigorously promoted and barriers to them, which allow discrimination to thrive, should be removed.

·        For prevention to succeed as it must, resources of an unparalleled scale are going to be needed.  UNAIDS estimates that at least four to five billion dollars are required annually for global prevention efforts, which is less than one percent of the world’s yearly military spending.  We can obtain some of this money through debt relief.  Today, African countries pay 15 billion dollars yearly in debt to international creditors, while owing them a staggering 230 billion dollars.  This means that they are transferring four times more to their creditors than they are spending on national health and education programs.  Progress has slowly been made in this area – some twenty million dollars were added to AIDS programs in African countries last year – but this is far short of what is required.  A massive escalation of resources is needed.

During the past few months, through the efforts of the Secretary General and others, a consensus has developed around the establishment of an international global fund to attract the resources needed for prevention and care.  In my mind, such a fund can make a difference if it attracts new resources (I believe the diplomatic word is additionality); strikes a balance between prevention and care; keeps policy- and decision-making at the national level; supports existing national programs and priorities, including the purchase of commodities; fully involves civil society and the private sector; has a streamlined and transparent secretariat that utilizes highly qualified technical advice and ensures accountability; and respects the principles of ethics and equity.  It should not seek to address all the world’s health problems, but rather focus on the devastating pandemic and its consequences that are before us.

Next week at UNGASS, there will be a historic opportunity, perhaps the best opportunity we have had during the past twenty years, to make all this happen.  World leaders last came together at a global level to confront the pandemic in Paris six years ago and signed a declaration of commitment, but little or nothing changed thereafter.  I saw all this with my own eyes. Will it be different next week?  Are 25 million deaths, the near devastation of the social fabric of many nations, and the real threat that this may happen elsewhere enough to rally world leaders to act, and not just sign?  Will this moment in history be seized?

·        It will take unprecedented cooperation among governments, foundations, civil society and industry to agree on priorities, strategies and specific goals and targets, for which all are accountable.

·        It will require governments to forego national and sexual politics and blame, and to acknowledge in the UNGASS declaration that vulnerable populations (to be explicitly named) exist everywhere, and are equally deserving of their human rights to prevention, care and social support.  When it comes to prevention, the gap between science and policy must close.

·        And it will require high-level leadership in all nations, not yet seen in the history of this pandemic.  By leadership, I mean commitment to a moral and humane approach to prevention, ownership of plans and programs, and above all else – courage – courage to talk frankly about human behavior without prejudice; courage to take on controversial issues no matter the political risk; and courage to generate a vision of new responses and understandings that, once and for all, bring an end to this pandemic.