Prevention or Treatment: A False Dichotomy?

by Dina Mikdadi  for Global Health Council, March 31, 2010

With only a slight increase in the Presidents Emergency Fund for AIDS Relief (PEPFAR) funding, are efforts better spent on prevention or treatment? This question has been asked since the inception of the program, but takes on new relevance in light of its slowed expansion and WHOs new treatment guidelines.

Support the prevention of more than 12 million new HIV infections.

Provide direct support for more than 4 million people on treatment.

Ensure 80% coverage of testing for pregnant women at the national level and provide treatment to 85% of those women found to be infected.

Ensure that every partner country with a generalized epidemic reaches a threshold of 65% coverage for early infant diagnosis at the national level.

These are just a few of PEPFAR IIs goals, as laid out by President Obama in his five-year plan last December. Current statistics remind us that we have a long way to go to reach these goals. There were 2.7 million new infections worldwide in 2008. That same year, 1.1 million additional people were put on treatment[i] . According to the WHO, only 21% of pregnant women received an HIV test in 2008 (up 15% from the year before), and only 34% of women testing positive actually received antiretroviral therapy.

Though these goals certainly are ambitious, they arent necessarily impossible given the proper resources. One wonders however, how any real progress towards these goals can be made with only a 2.2% increase in PEPFAR funding from the enacted FY10 budget to the proposed FY11 budget[ii]. With only so much money to go around, should some elements of PEPFAR receive more funding than others? The answer is yes, according to many experts, who say that preventing new infections is essential because it is cost-effective and saves more lives than providing treatment.

Researchers also point out that there are simply not enough funds to treat the growing number of people who are HIV-positive in addition to retaining those already on treatment. Others have said that the prevention versus treatment argument is simply a false dichotomy, noting that treatment can in fact lead to reduced risk of HIV/AIDS transmission by reducing ones viral load. Though this may be true, it may give the wrong message to people living with HIV and their partners. Behavior change, say experts such as David Halperin and others, is key to reducing HIV prevalence[iii]. Certainly, given the nature of the epidemic and the virus susceptibility to drug resistance, it would be impractical to stop providing treatment once initiated. Though pro-prevention experts do not advocate for this, re-orienting funds towards more prevention may mean that patients will be turned away due to lack of funds – this has already happened in places like Kenya and Uganda, where clinics funded by the US government have reached their quota of patients and are unable to accommodate new cases.[iv] [v]

The problem is compounded by the fact that the WHO has recently amended its guidelines on antiretroviral treatment, raising the CD4 count from 200 to 350. In Uganda, this could mean that the number of eligible people awaiting treatment could rise from 300,000 to 750,000 (an additional 4 million people worldwide would be eligible for treatment under these new guidelines). PEPFAR has admitted it still struggles to reach those with CD4 counts below 200, but plans to expand programming in order to meet the new WHO guidelines[vi]. Experts have said that the new guidelines could be lifesaving, but that implementation would depend largely on donor commitment.

In the midst of this intense debate on treatment access, countries such as South Africa are reporting that knowledge of HIV prevention methods has declined[vii]. With no clear resolution in sight, the consensus, at least for now, seems to be for striking some sort of balance between treatment and prevention. Yet this brings us back to beginning of the argument: with limited funds and concerns about donor fatigue, how are resources best allocated to ensure that PEPFAR achieves its goals? This might be a question aid-recipient countries will want to answer themselves.

[i] UNAIDS 2008 Report on the Global AIDS Epidemic: http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

[ii] Global Health Council; U.S. Foreign Assistance and Related International Health Programs Chart. Available from: http://www.globalhealth.org/global_health_funding/

[iii] Green, Edward C; Halperin, Daniel T. “Ugandas HIV Prevention Success: The Role of Sexual Behavior Change and the National Response. ” AIDS and Behavior. Volume 10, Number 4 / July, 2006Top of Form

[iv] Allen, Michael. “War on AIDS Hangs in Balance as U.S. Curbs Help for Africa.” Wall Street Journal. 1/30/2919

[v] IRIN. “Kenya: ARV woes push universal access off-track.” 3/13/2010. Available from: http://www.plusnews.org/Report.aspx?ReportId=88474

[vi] http://www.pepfar.gov/strategy/prevention_care_treatment/133372.htm

[vii] South Africa National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2008. Human Sciences Research Council. http://www.hsrc.ac.za/