Since the XIth International AIDS Conference in Vancouver last July, news of continued important treatment breakthroughs has raised hopes and expectations. Researchers have reported that the new protease inhibitors, taken in combination with other AIDS drugs such as AZT, ddC and 3TC, can reduce the amount of HIV in infected people to undetectable levels. Some scientists even speak -- cautiously about the possibility of eradicating HIV from infected people. As testimony to the optimism, the popular U.S. magazine Time proclaimed Dr. David Da-i Ho of Aaron Diamond Research Institute in New York as its 1996 "Man of the Year" for his scientific leadership in these treatment efforts.
The results from trials of a new generation of anti-HIV drugs are indeed encouraging. But the excitement over these findings has obscured what is -- and will continue to be -- our most potent weapon against the virus: prevention. Worse still, it may undermine prevention efforts by encouraging the mistaken impression that scientists have found a "cure" for AIDS.
Anyone who works in any area of reproductive health must remember the urgent and global need for effective HIV prevention strategies, and that this need will be with us for many years to come. For those who work primarily with family planning, seeking creative ways to incorporate appropriate, cost-effective STD/HIV prevention activities into their programs must continue to be a priority.1 Promoting condom use among clients at risk of a sexually transmitted disease is just one example of how family planning providers in many countries are already making an important contribution to HIV prevention.
No replacement
Although powerful antiviral drug combinations will make it possible to improve and extend life for many who are 
infected with HIV, drug treatment will never replace prevention. These therapies are already proving unaffordable for poor and underinsured North Americans. The cost -- at least U.S. $10,000 per patient per year -- guarantees that they will not be accessible to most people with HIV/AIDS in developing countries, where 90 percent of all HIV infections occur.
Even for those who can afford them, the drug "cocktails" are not a cure. We do not know how long they can keep the virus in check, and the drugs do not work for everybody. Moreover, compliance is difficult: the three drugs must be taken several times a day with more than a liter of water, some on an empty stomach and others with a high-fat meal.
The cost and complexity of the three-drug regimen and the remarkable ability of HIV to mutate more rapidly than any other known virus raises the specter of multiple drug resistance. If patients do not take the drugs correctly, or if treatment is interrupted because of adverse side effects or a patient's inability to afford a new prescription, strains of HIV will develop that are resistant to many, if not most, of the limited number of drugs currently available. These resistant strains will be transmitted to others, making the drug combinations powerless against HIV even in people who have never taken them.
Further research will undoubtedly lead to more effective HIV/AIDS treatments that are easier for patients to take, and we must fight to make these treatments accessible to all. One possibility is a two-tiered pricing system to make the new drug combinations affordable in developing countries. Companies that reap huge profits from HIV/AIDS drugs in industrialized countries have a moral obligation to work with governments, nongovernmental organizations (NGOs) and people living with HIV/AIDS to expand access to these life-saving therapies.
Support for HIV prevention research could pay even greater dividends. Through applied research by HIV/AIDS prevention projects around the world, we know that the three main strategies of FHI's AIDS Control and Prevention (AIDSCAP) project and the Joint United Nations Programme on HIV/AIDS (UNAIDS) -- communication to change behavior, condom promotion and improved STD services -- can reduce transmission of the virus. Studies sponsored by the U.S. National Institutes of Health-funded HIVNET (HIV Network for Efficacy Trials) Consortium in nine international sites managed by Family Health International will identify new tools to complement these three strategies in developing countries. Methods under study include vaccines, microbicides, new approaches to counseling, and prophylactic perinatal drugs.
Prevention works
Clearly, universal access to effective, affordable antiviral therapy is a distant goal. But the good news -- news that has made few headlines -- is that we can reduce the need for treatment. Data show that HIV prevention works -- and at a fraction of the cost of drug treatment.2
As in basic and clinical research on HIV/AIDS, years of painstaking research and practice in prevention are beginning to pay off. For more than a decade, public health professionals and educators have been refining effective approaches to slowing the spread of HIV.
We have figured out which strategies work and how to make them culturally sensitive, politically acceptable and economically feasible in some of the least developed regions of the world.
We have learned that some populations -- among them, women and young people -- are particularly vulnerable and require special programs that address their needs. And we've found out how to work with grass-roots organizations with strong community ties to ensure that prevention efforts can be sustained.
Here is what we have discovered:
Prevention education and communication can reduce risky behavior. Education, counseling and communication campaigns give people the knowledge, skills and support they need to prevent HIV transmission. In Uganda, for example, the "ABC" message (abstinence, behavior change or condoms) is reaching young people through schools, community outreach and the media, and a 35 percent decrease in HIV prevalence among young women attending antenatal clinics suggests a substantial reduction in new HIV infections among 15- to 24-year-old girls and women from 1990-93 to 1994-95.3
In the United States, Australia and Western Europe, HIV incidence appears to be stabilizing, largely because of effective prevention efforts within gay communities. Even while in the Rwandan refugee camps, where the daily struggle for survival made AIDS seem a distant threat, many have responded to prevention education by becoming more faithful to their partners.
Treating sexually transmitted diseases helps prevent HIV transmission.4 The presence of preventable STDs increases susceptibility to HIV infection as much as ninefold. Groundbreaking research in Tanzania has confirmed that STD treatment can reduce HIV transmission by more than 40 percent. This could make a big difference in the developing world, where most of the curable sexually transmitted infections occur.
Promoting condom use results in lower infection rates.5 In Thailand, aggressive condom promotion throughout the country and tough enforcement of condom use in brothels led to reductions in transmission of HIV and other STDs. Skyrocketing condom sales in countries where condoms could hardly be given away just 10 years ago are another indicator of the success of HIV prevention interventions.
Social marketing programs that make condoms more accessible and attractive to potential users have increased condom sales in countries from Haiti to Ethiopia to Nepal. In sub-Saharan Africa, annual condom sales rose from less than 1 million in 1988 to more than 167 million in 1995.6
Encouraging national policy change makes HIV prevention possible. Adopting policies that support rather than obstruct prevention efforts is one of the most important ways a government can protect its citizens from HIV infection. In Brazil, condom sales boomed after the government eliminated a 15 percent tariff on imported condoms. The Thai government's "100 Percent Condom Policy," which encourages consistent condom use among sex workers, has contributed to decreases in HIV and STD transmission, and has inspired similar efforts in the Philippines and the Dominican Republic. Throughout the world, when government leaders have spoken out about HIV/AIDS prevention, their openness has encouraged a more vigorous response to the epidemic.
Strengthening indigenous AIDS prevention organizations is the best way to reach communities and sustain prevention efforts. From 1991 to 1995, when political unrest and an international trade embargo paralyzed Haiti, Haitian nongovernmental organizations valiantly continued the prevention effort. With support from FHI's AIDSCAP Project, funded by the U.S. Agency for International Development, these small groups initiated effective prevention programs in workplaces, schools, churches and community centers, reaching both urban and rural populations. And in Tanzania, AIDSCAP has helped NGOs abandon competition and collaborate on prevention programs in the regions of the country most affected by HIV/AIDS.
Comprehensive HIV prevention programs have the greatest impact. Experience has shown that combining these prevention approaches multiplies their effectiveness, creating a social and political environment that supports sustained behavior change and reduced risk. Just as combination HIV therapies are more effective against the virus in infected individuals, combination HIV prevention approaches have a greater impact on the virus in populations where it is prevalent. Family planning professionals have a vital role to play in this comprehensive approach.
Best investment
Despite the success of these prevention strategies, and the continued elusiveness of an effective and affordable cure or vaccine, only a small percentage of the funding for global HIV/AIDS efforts goes to prevention programs. Yet even when an effective vaccine against HIV becomes available, it will not be perfect, and we will still need all the other prevention approaches working together in combination. Thus, these combination HIV prevention strategies in populations are analogous to our need for combination HIV treatment approaches in individuals.
This need is now greater than ever. As many as 40 million people will have been infected with HIV by the end of the decade. In some regions, entire generations will be devastated by the disease, leaving behind hundreds of thousands of orphans dependent on charity and social services. As workers in their most productive years succumb to AIDS and national health budgets are stretched thin by the rising cost of caring for the ill, the economic fallout will strain the struggling economies of developing nations. These pressures on fragile societies can intensify political unrest and instability.
If we fail to support HIV prevention while waiting for a medical "magic bullet," the consequences will be catastrophic. As we applaud biomedical advances in AIDS research, we must not forget that HIV prevention remains one of the best investments we can make in a healthier, more productive and more stable world.
Dr. Lamptey directs USAID's AIDSCAP Project and Dr. Cates oversees FHI's participation in the NIH HIVNET project. This article is adapted from one by Dr. Lamptey and Dr. Cates that appeared in AIDScaptions, a periodical published by the AIDSCAP Project.
References
- Cates W Jr. Sexually transmitted diseases and family planning: Strange or natural bedfellows, revisited. Sex Transm Dis 1993;20:174-78. Stein Z. Editorial: Family planning, sexually transmitted diseases, and the prevention of AIDS -- divided we fail? Am J Public Health 1996;86:783-84.
- St Louis ME, Wasserheit JN, Gayle HD. JANUS considers the HIV pandemic: Harnessing recent advances to enhance AIDS prevention. Am J Public Health, in press. Coates TJ, Aggleton P, Gutzwiller F, et al. HIV prevention in developing countries. Lancet 1996;348:1143-48.
- The Status and Trends of the Global HIV/AIDS Pandemic Symposium, Final Report. (Arlington, VA: AIDSCAP/Family Health International, Harvard School of Public Health and UNAIDS, 1996) 17.
- Dallabetta G, Laga M, Lamptey P. Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs. Arlington, VA: AIDSCAP/Family Health International, 1996; Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: Randominzed control trial. Lancet 1995;346:530-36; Committee on Prevention and Control of Sexually Transmitted Diseases, Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington: National Academy Press, 1996.
- Hanenberg RS, Rojanapithayakorn W, Kunasol P, et al. Impact of Thailand's HIV-control programme as indicated by the decline of sexually transmitted diseases. Lancet 1994;334:243-45.
- Population Services International sales reports, unpublished.
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