"Treatment is important, and we should take care of people who are sick," says Barry R. Bloom, dean of the Harvard School of Public Health and HHMI Medical Advisory Board member. "But if we don't prevent transmission, there will be even more people sick. The challenge is to get the most effective balance." The global fight against AIDS is not about treatment or prevention, but about both.

Indeed, a report released last July in Barcelona by UNAIDS (the Joint United Nations Programme on HIV/AIDS) recommended a minimum of $10 billion annually, largely subsidized by the world's wealthier nations, to achieve two critical goals: more affordable drugs and beefed-up prevention programs. Otherwise, it warned, more than 68 million people worldwide could die from AIDS over the next 20 years.

While the rate of new infections and mortality has been leveling off in the United States and Europe—thanks to prevention and the availability of therapy—the same cannot be said of the epidemic in developing nations. In sub-Saharan Africa, for example, 28.5 million people are living with HIV, but fewer than 30,000 are getting AIDS drugs. The disease is decimating the adult population, having already orphaned an estimated 11 million children in the region.

Also, infections are soaring among pregnant women. In Botswana, for example, HIV prevalence in this group was 45 percent in 2001.

However, public health experts say that isolated success stories prove that sustained prevention efforts—including the willingness to publicly talk about unprotected sex and other unsafe practices—and antiviral drug programs can have an impact.

"There are countries that have made marvelous progress, and in every instance, it relates to the government getting past its prudery," says June E. Osborn, a virologist who chaired the U.S. National Commission on AIDS and now runs the Josiah Macy Jr. Foundation in New York City. She cites Thailand, Uganda, Senegal, Ivory Coast and Brazil as examples of nations that have been able to turn the tide.

In Thailand, for example, "where young men in the military have a long tradition with sexual commerce, the yearly new-infection rate among military recruits was 20 percent," Osborn says. "The government did a turnaround on preventive messages about safe sex, and the rate dropped to 3 percent almost instantly."

In Brazil, the world's fifth-largest country, aggressive prevention messages and access to free drugs have resulted in a drop of HIV-related hospital admissions by 75 percent since 1997 and a decline in AIDS deaths of 50 percent, according to a 2002 Ford Foundation report.

"Curtailing HIV is in our grasp," Osborn says. "In those countries where they realize it's a matter of life and death, the simple messages that we have had from the beginning have worked."

Bloom agrees. "As primitive as the tools for prevention may be—condoms and exhortation—we know they are working in places like Senegal, Thailand and Uganda," he says. "HIV never rose in Senegal, and dropped dramatically in Thailand and Uganda. As nontechnical, unsophisticated and unappealing as it sounds, prevention can work. But it takes a huge effort."

—Marlene Cimons

Photo: Alexander Joe/AFP Photo

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Reprinted from the HHMI Bulletin,
December 2002, pages 12-17.
©2002 Howard Hughes Medical Institute