Looking the PEPFAR gift horse in the mouth

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.

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This post was published on 17/07/08 in Money and AIDS, The sex trade.

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  1. Comment by Jim, 17/07/08, 10:46:

    HOPEfully some of the funding restrictions will be taken care of by a new administration. I agree that the prevention aspects of PEPFAR represent a huge missed opportunity, both in the level and in targeting. However, I think we need to focus on growing the whole pie, prevention and treatment, albeit with a much larger focus on the former than what currently exists.

    One question, do you think you can reliably infer the impact of increased access to treatment on the behavior of uninfected persons in Africa based on research conducted in developed countries? I have only cursory knowledge of behavioral research in the U.S. and know nothing about Africa so I’d love to have some light shed on this issue. Thanks!

  2. Comment by Thomas Strong, 28/07/08, 08:14:

    Elizabeth, I’m curious what you think of recent numbers out of San Francisco and New York City that seem to indicate a continuing decrease in incidence over the last several years. Do these numbers problematize your thesis that risk behavior is on the rise in those communities, and do they further therefore problematize your thesis about the relationship between access to ARVs, perceptions of risk, and resulting behavioral change?

  3. Comment by elizabeth, 28/07/08, 09:56:

    Jim: “do you think you can reliably infer the impact of increased access to treatment on the behavior of uninfected persons in Africa based on research conducted in developed countries?”

    Reliably? No. For one thing, we’re unlikely to see as much of an “undoing” of safe behaviour in part because there is less safe behaviour to “undo” among heterosexuals in many African countries than there is among gay men in developed countries. But do I think it plausible that the relationship between percieved risk and actual behaviour will be similar. In communities where the major motivation for using condoms is avoiding death from AIDS, the disappearance of AIDS surely undermines the motivation.

    Thomas: The only NYC incidence data among gay men in NYC I know of are from case reports. Newly reported cases have drifted down slightly since 2001, but annual reports in gay men under 30 (those most likely to be negative, and to have come of sexual age in the post-treatment years) have risen significantly. In San Francisco, which has better trend data including from sentinel surveillance, incidence rose between 1995 (when HAART became available) and 2001 (along with several other markers of risky sex such as syphillis and rectal GC). This caused some alarm, and prevention efforts were strengthened, according to this interesting presentation from the San Francisco Department of Public Health. Incidence has since remained stable, as far as I know. I’d be only too happy to be corrected.

    My point is not that more treatment inevitably leads to higher incidence; it is simply that it is a likely consequence of a (very desirable) increase in treatment UNLESS WE ALSO do better at prevention.

  4. Comment by Thomas Strong, 11/08/08, 05:21:

    Hi there,

    I was thinking of recent reports showing sustained decline in incidence in SF and in NYC. For SF there is an article here:

    I do see the increase in transmission among young MSM that you indicate. I am not sure how I understand the idea that lack of fear of AIDS would impact this group differently than the 30+ group, where declines are reported. Can you make explicit your behavioral theory here and why there would be this differential response? Why would the ARV phenomenon differentially affect young ‘MSM’ versus older ‘MSM’?

    I think you have a great blog!

  5. Comment by elizabeth, 11/08/08, 06:42:

    Thomas: I’m not sure I have a theory; just observations. The clearest distinction between >30 and <30 is of course that those under 30 have become sexually active in the post-AIDS world. Could it be that while treatment makes AIDS less scary for older me, there is still residual fear associated with strong memories of friends infected and dying? These memories don’t exist for anyone who started having sex after around 1997.
    A second point about differing incidence: Among the over 30s, those most prone to risky behaviour will have been infected long ago. Among younger people the riskiest have not yet been “saturated”. While I know that risk varies over a life time, some of us are just more prone to expose ourselves to it than others.

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