Mead-
I agree we need a massive investment in prevention.
Some of that is about resources and money, but some is about the approach we’ve taken to HIV prevention. You refer to some of the mistakes we’ve made in your piece, such as focusing too broadly in prevention efforts, when they need to be targeted at those at highest risk.
When I got to GMHC in 2000, I was asked to take on HIV prevention policy. As a good activist, I first started looking about what we knew about HIV prevention, what had worked to shift epidemics on the level of populations. What I found was scandalous. A lot of interventions around the world were focused on changing individual behavior, rather than seeking to make community-level changes or changing the policies that drive risk in the first place. It’s as if in trying to stem automobile deaths, or gun violence, we had made a massive investment in sitting Americans down one-by-one to explain why they should wear seat-belts, or how guns kill people. That is to say, we’ve never taken a public health approach to HIV prevention.
What gets trumpeted are a few examples of effective HIV prevention, like the 100% condom campaign, needle exchange, or circumcision, but no one ever says we are in a terrible state when it come to knowing how to prevent infections, that we have far too evidence-based tools at our disposal to make a big impact. If HIV prevention was treatment, we’d be back in the days of AZT alone. We need to become activists for better prevention, better prevention research, new ways of thinking. Simply talking as if it’s just about the money, let’s everyone off the hook for our failures in this field. It also will foster the continuation of the waste of millions of dollars on things that don’t work. Let’s get to work on HIV prevention, but let’s not pretend it’s a matter of simply more cash. And it’s not just about ideologues on the right or left who are creating problems in HIV prevention—it’s from within the field itself, from vested interests, fossilized thinking, a lack of self-criticism or analysis.
You talk like an economist—well, you are one! First we get infections down, then we can resume scale-up of treatment. I wish it could work that way. You know that knowing one’s status is a key part of HIV prevention—people who know they are HIV+ are less likely to transmit the virus. We also know that offering ART is a strong incentive for HIV testing. In Khayelitsha in Cape Town, ART increased testing rates, STI rates went down and there a plenty of other examples of ART bringing new people into HIV services, including those for HIV prevention. If we stop or slow treatment now, the incentive to know your status is greatly reduced. In addition, we know ART reduces viral load—despite the grandiose claims of some that we could stop the epidemic in five years with nationwide ART in some places, the truth is probably more modest but significant nonetheless: ART can blunt new transmissions if coverage is wide enough. And as Helen Epstein and others have remarked part of the best HIV prevention is mobilization, when communities get together to combat a danger in their midst together. ART has been a great community mobilizer across the globe, and not just for AIDS treatment, but a variety of HIV prevention work, from needle exchange and substitution therapy in the former Soviet States, to gender violence/rape prevention in South Africa. You and Bill Easterly like to talk about the separability of HIV treatment from HIV prevention, which flies in the face of what the people who actually work on service provision know—an integrated, comprehensive, community-based approach is best, working with communities to figure out what they need.
I think the separability of treatment and prevention is important for you and Bill because you simply—as you once said to me—think health care, ART provision is not a public good. As you told me: ART is like a loaf of bread, you consume it on your own. Well, first we know that ART has community level impact, so it is a public good as well. But the disagreement is more fundamental. You worry that AIDS care will gobble up foreign assistance if it is allowed to continue. For you, despite the fact that trillions materialize for bailouts of banks, countries, and car companies, you insist that foreign aid is fixed, by assuming this you accept it as a unchangeable reality and make the case to the rest of the Beltway crowd that it should be.
When you talk of ART as an entitlement, I apologize but all I can hear is the voice of Ronald Reagan, decrying “welfare queens” and people living off the tit of the public sector. You know historian Tony Judt wrote a book recently called Ill Fares the Land, it’s about the rise of free-market libertarian economics over the past 30 years, the rejection by policy makers of a mid- 20th century consensus on social welfare and social democracy. Part of your analysis and Bill’s is part of what Judt talks about—a rejection of the role of the state, or at least a substantial downgrading of the state’s role in social welfare. Nations, and the community of nations and the people who live in them should look to democracy and the market for their futures, not to their governments for the sons of Milton Friedman.
As my mother says: what do you think? Money grows on trees? No, mom, I don’t. However back in the 1990s, we had a battle called the “disease wars” around NIH funding—the refrain was similar to today’s: AIDS gets too much money compared to other bigger killers. We made the same case we make today-the investment in AIDS, in prevention AND treatment, and research is vital. But it was Christopher Reeve who came to the rescue, Superman that he was. His foundation joined with us to say, we need to work together to lift all boats, and boost the NIH budget, let’s double it. Guess what: it worked: we got the NIH budget doubled in the 1990s. Sometimes money does grown on trees.
Yes, there are limits, but if we could get all OECD countries to put up 0.7% of their GDP, we’d be making far fewer Sophie’s choices. Governments have made commitments to these sums already we’re not asking for anything new. There will always be trade-offs, we triage now. But if we treat all of this a zero-sum game for eternity, we are doomed. We have too much to do in HIV/AIDS, in TB, maternal and child health, health systems, sanitation, education, housing, the environment to settle for this. In the end this is about the planet we want to live on, the kind of world we want it to be.
You and Bill tell leaders what they want to hear: go back to the old ways before these uppity activists started calling out governments on health care. You know several of my colleagues got thrown out of Tanzania last week for trying to simply hand over a memo to leaders assembled at the African Economic Forum in Dar es Salaam about the need for African leaders to invest in health, not in self-enrichment, Mercedes-Benzes and fighter jets. By and large these were young people, speaking up, risking arrest, young Africans saying the world can be different. When the history books are written, I want to be on that page with them, not among the purveyors of the status quo, who have always said, wait, we can’t do this, it will ruin the economy (e.g. FDR’s critics during the New Deal, LBJs during the Great Society), we can afford it, be patient, we’ll get to it some day. You will say that oh, I am just a dreamer. Well, no actually. Ill does far the land. The sickness is among those who are defenders of 30 years of economic ruthlessness disguised as sound policy. You say we can’t afford ART. I say we cannot not afford it.

Surely treating people and extending lives are only part of the equation—and that a balanced response where prevention takes on greater importance is vital.

However, unfortunately, failed policies and the absence of sustained leadership are beginning to reverse gains, constraining service providers to once again make painful decisions about “who lives and who dies” as one NY Times letter writer describes:

http://www.nytimes.com/2010/05.....5aids.html

As a global community, we should do much better.

Hi, Mead.
I agree that we can’t simply focus on AIDS treatment and not address the expansion of the queues of those waiting by failing on HIV prevention. I don’t think anyone in their right mind could disagree!
Sadly, my sense is that there HAS been an investment in HIV prevention and as I mentioned above, but it has been spectacularly unsuccessful. Does this mean we give up? Hell, no.
But we need to take on the prevention mafia and clean house (sorry for the mixed metaphors)–let’s analyze where prevention money has gone to date, what we’ve got for our investment, bring together experts (from AIDS and non-AIDS disease prevention fields) to assess what “combo” prevention regimens might work and where and then go get the money to fund it. This is what we’ve done as activists in almost all areas of HIV/AIDS programming–but somehow prevention has escaped any rigorous critical analysis, except probably among those working on these issues in terms of intravenous drug use. I say this as part of the Global HIV/AIDS Prevention Working Group, sponsored by Gates and Kaiser: I haven’t seen us reflect on our failures and do any real hard thinking in the several years I’ve been part of this group. I can tell you to raise these issue will get you in trouble–there is strong resistance to change in the HIV prevention field.
One thing I would like someone to do is to calculate the prevention benefit of ART–not as part of grandiose schemes of full coverage of ART, but in real terms. What do we get for 4 million people on treatment now in terms of infections averted? And yes, we need to ensure better adherence, which to me means engaging people on ART through “treatment literacy”. However, there is little appreciation among clinical types for this kind of active health education.
Finally, I hope that in the zeal towards horizontal programming, people realize that health systems need breadth and focus–pendulum swings too far in either direction aren’t productive…
On a last note, no one thought ART would become an entitlement 10 years ago. I’d rather call it a right–I know it won’t sit well with you but I do think the poor have a right, an entitlement to health. We can only hope for the expansion of these rights and entitlements to take on more areas of health and development in the future, which means we have to stop thinking of things as a zero-sum game. We know that money “appears” out of thin air when it is needed for rescues of Wall Street firms, wars and other priorities. We can afford to do these things, in fact, don’t really blink an eye at these vast sums, but somehow get caught up with penny-pinching with health and development. We broke through a threshold in 2000 in the scale-up of ART-we have to keep pushing forward, expanding the scope of health care for the poor. Some will say it’s unsustainable, but how is allowing inequities to expand, disease to spread, sustainable in the long-run?

I can’t say that I know as much about this subject as the other commentators here, however I would say that the rate of funding for AIDS is likely to diminish whilst the world’s economy is under pressure, which has been the case since around 2008. Also, in reference to something Gregg said “What I found was scandalous” – I think that governments in the worst affected regions of the globe are simply overwhelmed by agreeing to international policies (official or unofficial), that conflict with other efforts in either an accidental or deliberate way. Please read between the lines here as I do not want to make it too obvious.