Then, three months ago, came an article in the New England Journal of Medicinetitled “Prevention of HIV-1 Infection with Early Antiretroviral Therapy.” The study found a 96 percent decrease in transmission to a heterosexual partner when AIDS treatment was begun early. Treating AIDS sooner than later is a dramatically effective form of AIDS prevention.
Scientists began considering something previously unimaginable. What if these methods of AIDS prevention were combined — along with condom use and the prevention of mother-to-child transmission — and aggressively applied in the most affected regions and among the most vulnerable groups in Africa? Scientific models project that transmission rates, already declining in most places, would fall an additional 40 percent to 60 percent.
This raises a prospect comparable to medical achievements such as the eradication of smallpox or advances in cancer treatment. Currently, for every new AIDS patient put on treatment, about two more become infected. Millions of lives are saved — but ground is still lost to the disease. With combination prevention, the balance would shift. For every person who begins treatment, there would be fewer than one who becomes infected. This would effectively be the epidemic’s end.
The Obama administration has officially adopted the goal of “creating an AIDS-free generation.” “While the finish line is not yet in sight,” said Secretary of State Hillary Rodham Clinton on Tuesday, “we know we can get there, because now we know the route we need to take. It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other.”
But the political timing of these scientific breakthroughs is poor. The budget crisis has resulted in a Darwinian competition for resources. Clinton accompanied her ambitious AIDS objective with the not-very-ambitious reprogramming of $60 million for demonstration projects in four countries.
Additional resources can eventually be squeezed from existing AIDS programs. In 2004, the cost of treatment averaged about $1,200 per person. Today, it is less than $350 and still declining. Other donor nations, along with African countries themselves, can take additional burdens.
Yet the objective is not a minor one. Earlier AIDS treatment in the developing world would expand the pool of people in need of medicine. In the main U.S. HIV/AIDS program, Africans currently start drugs when their CD4 count — the measure of immune system strength — is, on average, about 150. Beginning at a CD4 count of 350 — the recommendation of the World Health Organization — would increase the number of Africans on treatment by more than 5 million. An aggressive treatment-as-prevention program would start treatment even earlier.
In normal economic times, the case for this effort would be fairly easy. American spending on all humanitarian aid programs amounts to about 0.7 percent of the budget. What other marginal spending increase could save millions of lives, end an epidemic and allow public officials to take part in a historic enterprise as admirable as the Marshall Plan? The proposed prevention strategies do not involve much culture war controversy. Religious conservatives have no objections to treatment and are neither shocked nor alarmed by circumcision — an old biblical acquaintance.
But with economic times far from normal, the case is complicated. Ending the global AIDS epidemic would require a major presidential push. It would also require congressional Republicans to make a human life exception to austerity.
This uphill effort would, however, be aided by a pragmatic argument. Since 2003, the United States has helped place millions on AIDS treatment. In the process, we have assumed what economists call a “treatment mortgage” — obligations that can’t be abandoned without catastrophic consequences. A major prevention effort — reducing the number of new infections to below the number of new people placed on treatment — is the only morally acceptable strategy that eventually reduces American commitments on AIDS.
Having abruptly gained the scientific tools to defeat this epidemic, what remains is a test of will and conscience.