Preventing infections may lack the glamour of saving the sick, but it remains the key to ending AIDS. What are the obstacles, and what will it take to surmount them? NEWSWEEK’s Geoffrey Cowley spoke to Dr. Helene Gayle, the president and CEO of CARE, a humanitarian organization, and co-chair of the International AIDS Conference. Excerpts:
NEWSWEEK: International funding reached $8 billion this year. Why have we had so little luck in stopping the spread of HIV?
Dr. Helene Gayle: Over the last few years, attention has shifted to treatment and away from prevention. It’s no surprise. Unlike prevention, which involves taboo subjects like sex and drug use, treatment is a more neutral issue. When you have the tools to keep huge numbers of infected people from dying, you have to do it. We absolutely should not cut back on treatment. But we’ve got to do more to integrate better prevention and treatment. If we don’t, we’ll fail. Part of the problem is that you have different people focusing on different parts of the response. You have doctors focusing solely on treatment while community organizations try to handle prevention. Too often, they’re not working together. Testing, treatment and prevention counseling need to be much better coordinated.
What lessons have we learned about prevention? Have the efforts of the past 25 years made any appreciable difference?
Prevention is invisible. When it works, nothing happens except that people who were healthy stay that way. We’ll never know exactly how many of the people now using condoms or abstaining from sex or sticking to one partner might have ended up HIV-positive otherwise. We can’t purposely exclude people from prevention efforts to find out. But it’s clear that prevention efforts can work. HIV rates have decreased in countries like Uganda and Thailand and now in some countries in eastern and southern Africa. When people enroll in trials to test microbicides [topical agents that may prevent HIV transmission] or preventive drug therapies, their rate of HIV transmission often drops because they receive intensive prevention counseling, access to condoms and treatment for their other sexually transmitted diseases. This may explain why the first microbicide trial, done several years ago, couldn’t detect a difference between those who used the product and those who didn’t.
But most people now know how HIV spreads. Knowledge alone doesn’t seem to provide much protection.
Information and education are critical, but they’re not enough. When Thailand wanted to stop HIV transmission in the brothels, it didn’t just suggest that people use condoms. It took a proactive approach and adopted a 100 percent rule. Brothels that didn’t enforce condom use were shut down like restaurants with code violations, and it worked. The transmission rate fell and the country averted a disaster.
The Bush administration’s ABC approach [abstain, be faithful, use condoms] has been criticized for overlooking the social issues that place women at risk. If your partner isn’t faithful, and you lack the power to refuse unprotected sex with him, ABC doesn’t offer you much protection.
ABC can work if it’s part of a balanced and comprehensive prevention strategy. Uganda’s experience shows that. When children started delaying their sexual debut, and people embraced condoms and partner reduction, the infection rate came down. But there are limits to that approach, especially for women. Social, cultural and political factors make some people more vulnerable to HIV. If you’re a woman lacking food for your kids, sex may be the only asset you can sell. You’re not in a good position to dictate the terms. Women who are themselves monogamous may be in relations with partners who have multiple partners and won’t use a condom. Women in many societies don’t have the social power to negotiate safer sex or control sexual interaction, including within marriage.
Is anyone coming up with good, practical ways to address these deeper sources of risk?
I just visited a community-based savings-and-loan program that CARE supports in Guatemala. CARE has similar programs in Africa and in Asia. This program provides small loans that women can use to start businesses if they send their daughters to school. Woman after woman described how earning money had raised her stature within her family and marriage. The girls said the same thing about going to school. They were headed for lives where they would be able to make their own choices. We can’t do away with poverty overnight, but we can counter some of its worst effects. We also need to change the social norms that condone coercive sex and treat women as property. How do you make it unacceptable for schoolmasters to harass young girls? You prosecute them for it.
What are the big remaining challenges for governments and foundations and international health agencies?
We need to develop new tools. Diaphragms, circumcision, microbicides, treatment of herpes, oral prevention drugs and, ultimately, a vaccine—these technologies may all have roles to play. We’re making rapid progress toward effective microbicides, and we can hope that antiretroviral drugs will help prevent HIV infection as well as they treat it. But these technologies are at least five to seven years from the market, and technology alone won’t solve the problem. Condoms are cheap, simple and highly effective, but they’re still underused. Only one in five people at risk for HIV has access to existing prevention approaches like education, condoms, HIV testing and treatment of other sexually transmitted disease. Even the best prevention programs typically reach only 10 to 30 percent of the people who could benefit. We need to get to a tipping point where we’re reaching at least 50 percent of people at risk. Then we will start to see greater impact.
