Curtailing the HIV
Epidemic: The Power of Prevention
H. Merson, M.D.
of Public Health, Yale University
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.
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.
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.
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.
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.
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.
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
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
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
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.
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 Banks 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.
of this seachange is due to increased awareness about
the pandemics 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
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
the first time in the pandemics history, comprehensive AIDS
care is now a reality, for everyone.
this is the context in which HIV prevention now operates, what
should be the main elements of an effective prevention
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.
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.
is not possible here to review the evidence for effective
prevention in detail, but there are elements of successful
prevention programs worth emphasizing.
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
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
successful prevention programs involve those who are infected
by the virus, as well as members of civil society, ranging
from womens groups, to gay mens AIDS services
organizations, to families caring for orphans.
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.
successful prevention programs are multi-faceted and multi-sectoral
there is no single magic bullet.
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.
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.
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.
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
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
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
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 bodys viral load.
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 nations economic development
and help to maintain national security.
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.
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
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.
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.
conclude now with some thoughts on how we can take HIV
prevention to the scale required to curtail the spread of the
need, first and foremost to apply, at dramatically increased
levels, what we have learned over the past two decades about
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.
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.
need to take far more seriously the importance of reducing the
social and economic vulnerability of those susceptible to HIV
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
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 worlds 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 worlds health problems,
but rather focus on the devastating pandemic and its
consequences that are before us.
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?
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.
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.
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.