The bill allowing another US$ 50 billion of US taxpayer’s cash to be spent on HIV in developing countries has finally been given the thumbs up by the Senate. There’s good and bad drafted on to the PEPFAR legislation. The good is the dropping of a law which forbids foreigners with HIV from sullying the shores of the United States. The bad is a panoply of silly rules which mean that the money will do very little to prevent new HIV infections in adults. In fact, PEPFAR will almost certainly lead to more HIV infection in Africa, not less.
Most of the money will be spent on drugs to keep people with HIV alive. This is necessary, and wonderful for the individuals who are getting the drugs. But it does mean that there will be more people with HIV. It also means there are more people who can pass it on. Granted, HIV treatment reduces the amount of virus in body fluids, and makes it more difficult to pass on. It also prevents AIDS, sickness and death. So it makes the consequences of HIV less visible. The evidence suggests that this in turn makes uninfected people more careless about who they have sex with, and sloppy about using condoms. And that in turn makes them more likely to have unprotected sex with someone who is infected but not yet on treatment. Newly-infected people are both most likely to be highly infectious and least likely to be on treatment. Indeed most still count themselves among the uninfected. So while treatment decreases the likelihood of infection for individuals on meds, it can increase new HIV infections across a whole population.
That’s what seems to be happening among gay men in countries where access to treatment is near-perfect: in Britain, the Netherlands, Canada, the United States and Australia, new HIV infections among gay men are rising. The effect of rising risk behaviour weighs more than the effect of lower viral loads. In Africa, it’s likely to be worse. Crappy health and transport systems and erratic incomes may mean people have difficulty getting the drugs they need when they need them. Other STIs are high too, and both of those things can send viral loads bouncing all over the place, even for those on treatment.
Of course we need to get antiretrovirals to as many people in need as possible. But if we want that to remain plausible and affordable, we have to stop people getting newly infected, too. The only developing country that’s managed to prevent new infections while putting everyone in need on meds is Brazil. The country invests very heavily in needle exchanges for drug injectors, in promoting condoms to young people, and in good health services for sex workers. So will PEPFAR copy this shining example? Uhhh, no. There’s US$ 50 billion on the table, but not a cent for clean needles for injectors. Not a cent for sensible prevention programmes in the sex trade. A full half of the prevention money (some five billion dollars in all) must be spent telling kids to cross their legs, even though we know that abstinence programmes don’t work. (If people allocating PEPFAR money in countries want to throw less than half of their prevention money into this black hole, they have to make a special report to Congress.)
There’s still a little bit of negotiating to do on the bill because the versions passed by the House and the Senate are different. (This means that the understandable jubilation over the end of the HIV travel ban may just be premature.) But if all the current amendments stick, the US tax payer may well be financing the growth of the HIV epidemic.
For a blow-by-blow account of the Senate debate, read Scott Swensen’s account.