One of the most uncomfortable and encouraging conversations I’ve ever had took place a few years ago at an overcrowded AIDS testing clinic in Addis Ababa, Ethiopia.
A nurse had asked me if I wanted to meet one of the women using the clinic’s services. I assumed I’d be talking to someone who’d received a negative report. Speaking through an interpreter, I discovered that the young girl sitting across from me was still waiting for the result of her test. I awkwardly assured her that I wouldn’t disturb her any further. She interrupted: “A few years ago, I would never have talked to a foreigner about AIDS. But now I know that even if I’m positive, it isn’t a death sentence. Three of my friends have already been tested, and I need to know.”
This is one reason AIDS drugs, when they arrive, are such a miracle. Without the realistic hope of treatment, there is little motivation to be tested; most of us would prefer denial to hopeless certainty. And without AIDS testing, preventing the spread of the disease is difficult; denial increases risky sexual behavior.
More than 2 million men, women and children are getting AIDS treatment in the developing world — up from close to zero five or six years ago. Health professionals have demonstrated, against considerable skepticism, that complex drug therapies are possible in impoverished countries. And America has taken undeniable — even though broadly denied — leadership in these efforts, currently providing more funding to fight AIDS in the developing world than all other nations combined.
This moral achievement is impressive until it is compared with the scale of the problem — about 40 million people living with HIV-AIDS. In 2006, there were more than 4 million new infections, far outpacing the growth of treatment. At ground zero of the pandemic in sub-Saharan Africa, about a quarter of those who need the drugs are receiving them. Even countries that have reduced new infections, such as Uganda, are still overwhelmed by the demand for treatment. Efforts to treat AIDS have increased massively, dramatically — and we are still losing ground.
So a debate has begun. Is the goal of universal access to AIDS treatment by 2010 — adopted by the United Nations and the wealthy Group of Eight nations — realistic? Will larger treatment efforts be sustainable as infections rise and resistance to cheaper, first-line drugs develops? Should more resources be shifted toward prevention instead of being “wasted” on lifelong treatment?
There is no doubt — short of an effective AIDS vaccine — that prevention is the long-term solution to the AIDS crisis. Some preventive measures are technological and medical — ensuring safe blood transfusions, circumcising males to lower the risk of infection and administering drugs to prevent mother-to-child transmission.
But AIDS prevention depends largely on changed sexual behavior, which is much more complicated than an operation or a pill. Those looking for a single, magical, preventive technique — either condoms or abstinence — will be disappointed. Nations that have made progress reducing HIV infection rates, such as Zambia, Rwanda and Kenya, seem to try everything at once. They have achieved delays in the onset of sexual activity, especially among girls, which argues for the promotion of abstinence among the young. They have seen declines in multiple sexual partners — which recommends a message of faithfulness. And they have seen increases in condom use during casual sex — which calls for the broad availability of condoms.
All these efforts deserve increased support (contrary to some angry and uninformed accusations, condom distribution by America in the developing world increased 70 percent in the first four years of President Bush’s emergency AIDS plan). But can these efforts take the place of treatment? And should they be funded at its expense?
As a young woman taught me in Addis Ababa, testing is difficult to promote if AIDS is a death sentence. Treatment and prevention, in the end, cannot be separated. And the goal of universal access to treatment seems morally unavoidable. However expensive this commitment might be, there is also a cost to letting 40 million people and more die — a cost the world should not be willing to pay.
But we also need to be realistic about the nature of this commitment. Defeating AIDS will require major new efforts in prevention. And moving toward universal treatment, according to the United Nations, will require between $32 billion and $51 billion by 2010.
America has done much — and still we face an ocean of need.