I can only express admiration for the advances made possible through biomedical research. In 15 years we’ve learned an enormous amount about the AIDS virus and the way it infects our white cells. This basic science has allowed rapid development, testing and licensing of these new drugs that inhibit viral replication. As someone who has seen firsthand, in scores of countries, the suffering brought about by the disease, I feel great joy that some HIV-infected persons can now live a longer life than was dreamed of two years ago.
Despite these achievements, there are still unknowns and potential long-term problems in controlling the disease. One major concern is whether HIV strains resistant to the new drugs will eventually develop, especially if the drugs are not taken in full dosage and on the required schedule. The three-drug regimen–as many as 20 pills a day–is daunting and can cause debilitating side effects. We’ve had antibiotics for treatment of gonorrhea for 50 years, but because of their inappropriate use, we have been forced repeatedly to develop new drugs to treat resistant strains. Tuberculosis has been treated with triple-drug therapy for more than 25 years, yet it is still a leading cause of death among adults worldwide and has only recently been brought under control by having health workers stand over patients at home or in clinics to make sure they take all the prescribed pills.
Another hurdle is making these costly drugs available to those who need them. This will be difficult in the United States and virtually impossible in developing countries, the home of more than 90 percent of the world’s HIV-infected population. Beyond that, monitoring the level of virus in a medicated patient’s blood to determine the drugs’ effectiveness will be expensive.
But the most serious downside to the latest therapeutic breakthrough could be its impact on AIDS prevention. I can hear it now. If we are close to a cure, people may say, why bother with politically sensitive activities such as condom promotion, sex education in schools or disease-prevention programs for illicit drug users. Let’s not invest further in trials of protective vaginal products or genetically engineered vaccines. Wouldn’t the money be better spent for heart disease and cancer research?
Lost amid the excitement in Vancouver about a potential AIDS “cure” were numerous reports about prevention measures that are working in many places-from San Francisco to Bangkok to Abidjan. We heard about the success of syringe-exchange programs and learned that the failure to implement them during the past decade has led to thousands of preventable HIV infections among injecting drug users and their noninjecting (usually female) sex partners. We were told how community-based activities were resulting in safer sexual practices among inner-city women, men who have sex with men, and high-risk adolescents. There was definitive evidence that correct antibiotic treatment of common sexually transmitted diseases greatly diminishes HIV transmission. Finally, we heard about the slow but steady progress in development of an AIDS vaccine and preventive vaginal gels for women.
During the past decade, we’ve been able to provide more scientific evidence for the success of AIDS-prevention strategies than exists for many other diseases. Despite these achievements, political support for AIDS-prevention programs has been declining. Federal funding for AIDS prevention at the Centers for Disease Control decreased by $5 million this year. No doubt this is because the highest rates of infection have been among socially marginalized populations (gay men and drug users) and African-Americans and Latinos who lack political influence. Viewing the epidemic as a moral issue adds to the problem.
Prevention will always be a thousand times more humane and cost-effective than treatment. Since half of HIV-positive Americans are unaware they’re infected, the virus will continue to be transmitted despite the availability of antiretroviral drugs. At the conference, Health and Human Services Secretary Donna Shalala pledged action for prevention programs and research. Will it result in an increase in resources and full support for programs we know are effective?
Since the epidemic began, more than half a million Americans have developed AIDS; three out of five have died. AIDS is now the leading cause of death of men and women between the ages of 25 and 44 years in our country. The number of cases is increasing most rapidly among women and among those infected through heterosexual contact. Some 40,000 to 50,000 Americans are infected with HIV yearly. Half are under the age of 25. Worldwide, 8,500 people are infected daily. These numbers are unacceptable for a preventable disease.
I believe that we can now make huge inroads in treatment by widespread access to antiretroviral drugs. But equally important is political and financial support for prevention. We need to educate our youth on how to protect themselves, expand syringe-exchange programs for drug users and encourage safer sex with condoms for those at risk. Care and prevention together can save millions of lives. Then we’ll have real cause for celebration.
