A Cocktail for Prevention

Passing out condoms didn't work. Neither did abstinence. Stemming HIV will require a combination of creative approaches.

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Increasingly, however, as the HIV/AIDS epidemic continues to rage, the appetite to understand what's fueling the spread has grown. At past International AIDS conferences, a session on prevention wouldn't have drawn enough attention to fill a large meeting room. In previous years, treatment totally dominated the conversation.

But this year the theme of prevention has bubbled to the surface among the tangle of panels and workshops, debates and discussion among the 22,000 attendees in Mexico City. Tuesday's plenary session on the topic was filled to capacity and several other sessions hummed with interest and energy. At the Lancet Series on HIV Prevention, hundreds of people packed into the session room, and many others watched on big-screen televisions in an "overflow" room, while others stood outside, unable to get in.

And it's not just prevention as usual. Throughout the conference, scientists and activists have called for innovative new ways to stanch the spread of HIV throughout the world. The most common methods—teaching people about the disease, distributing condoms and telling them not to have sex—aren't working, at least not well. Last year, 2.7 million people were newly infected, most in sub-Saharan Africa.

"Prevention has not only been marginalized, but in some places it's been suppressed for political, religious or social purposes," said Richard Horton, editor of The Lancet, a British medical magazine that devoted its most recent issue to HIV prevention. "We have to redefine prevention, to create a new dialogue of what we mean by prevention."

"Combination prevention" is the hot new buzzword. This means, simply, combining various prevention strategies to decrease the spread of HIV. Too often, our prevention framework is one size fits all. Hand out condoms and call it a day. Or, in the United States, fund only prevention programs that teach abstinence to the exclusion of comprehensive sexual health education.

Or the latest magic bullet: circumcision, which has been shown to reduce the spread of HIV from women to men during heterosexual intercourse by 60 percent. Men in Kenya and other African countries have reportedly been lining up to get "cut." But what about the other 40 percent? And what about male to female transmission and male to male—by far the more common forms of transmission in the United States? Circumcision, condom distribution or abstinence education, in isolation, is not and has never been the answer.

"There will never be a single magic bullet to prevent HIV transmission," says Nancy Padian, executive director of the Women's Global Health Imperative in San Francisco. "A combination prevention package is what's most effective."

In the United States, we have no bullet or package; the federal government has done little to prevent the spread of HIV among African Americans. Since 2001, there has been no real national HIV prevention plan. The previous strategic plan was extended in 2006, but it is anemic at best. What exists has been patchy, piecemeal, one-dimensional and under funded. That neglect has taken its toll. New U.S. statistics released last Saturday show that the number of people infected with HIV every year is 40 percent higher than the federal government has been reporting each year. And the rate of new infections among African Americans is seven times higher than among our white counterparts.

"I am disgusted and frustrated by my government's response to AIDS," said Pernessa Seele, founder and CEO of The Balm in Gilead, a nonprofit organization in Richmond, Va. that mobilizes churches in the fight against AIDS. "In black America, there is no plan."

And though the United States should be applauded for leading the world in global HIV/AIDS funding, it has failed to funnel much money to our national problem. PEPFAR, the $48 billion legislation to fight AIDS and other diseases overseas that now sits on President Bush's desk—triple the amount from 2003—does little for the millions who are newly infected and living with the disease in our own backyard.