AIDS: The Strategy Is Wrong

By Richard Holbrooke
Tuesday, November 29, 2005

Thursday is the 18th annual World AIDS Day, a time for countless statements of concern and commitment from world leaders, thousands of commemorations and remembrances, and reams of statistics. One important article has already appeared on this page, by Jim Yong Kim, the highly respected director of the HIV-AIDS Department of the World Health Organization [Nov. 23]. After recounting the grim statistics -- 3 million deaths in the past year alone, 5 million new infections this year, rising infection rates in nearly every part of the world and an admission that "good news is hard to find in the new U.N. report" -- Kim wrote that he was nonetheless "optimistic that the epidemic can be stopped."

I respect Kim and admire his commitment, as well as that of every foot soldier in this war. I share that commitment. With respect, then, to my friends and colleagues in the field -- most far more qualified than I am -- I must nonetheless mark World AIDS Day with a word of pessimism that they will not necessarily welcome. We have to face the truth: We are not winning the war on AIDS, and our current strategies are not working. Every year since the first World AIDS Day, the number of people affected has increased. The very best that can be said is that we are losing at a slightly slower rate.

The huge, and very expensive, international effort has saved the lives of a growing number of people. I have seen some of the beneficiaries of these efforts firsthand in places as remote as rural eastern Uganda -- and it is inspiring. The international assistance effort must be continued, indeed increased.

But as Kim acknowledges, "fewer than one in five people at risk of HIV infection has any access to HIV prevention information," and this must be addressed with larger internationally supported programs. (But remember, once a person is on the drugs, it's for life; to stop taking them is to be hit with a mutant of the original virus.) Until a vaccine is found -- and that is probably more than a decade away -- we must focus on prevention and treatment. Providing treatment is essential, of course, but it is also a bottomless pit as long as the disease continues to spread so fast.

As a strategy, losing more slowly is simply a recipe for an ever-more-expensive, disastrous and deadly failure, which will require more anti-AIDS drugs at ever-greater cost -- a modern version of the old story of the boy with his finger in the dike. Moreover, as Kim points out, current policies require "building and strengthening health care systems in the developing world." This is an essential long-term task with or without the AIDS crisis, but one so daunting that linking it so closely to stopping the spread of AIDS only compounds the odds against reaching either goal.

Only effective prevention strategies can stop the spread of AIDS. Yet it is precisely here that current policies have failed most seriously. In the long chain of actions required to stop the spread of AIDS, attack on all fronts is necessary. But on one vital front, the world health community has been shamefully quiet for two decades: testing and detection. Because of legitimate concerns about confidentiality and the risk of stigmatization, testing has always been voluntary, and it has been systematically played down as an important component of the effort.

The results are predictable -- and fatal: According to U.N. figures, over 90 percent of all those who are HIV-positive in the world do not know their status. Yet there has never been a serious and sustained campaign to get people to be tested. That means that over 90 percent of the roughly 12,000 people around the world who will be infected today -- just today! -- will not know it until roughly 2013. That's plenty of time for them to spread it further, infecting others, who will also spread it, and so on. No wonder we are losing the war against AIDS: In no other epidemic in modern history has detection been so downgraded.

When I first suggested, about three years ago, that testing and detection was the weak link in the strategy against AIDS, I was sometimes criticized for ignoring human rights. Having worked in support of human rights for more than three decades, I understand this issue and the passion it arouses. I have met monogamous women who were thrown out of their homes for a disease they got from their husbands, and people who lost jobs and friends once their condition became known.

But the spread of the disease cannot be stopped, and we cannot offer drugs to those who need them, unless people know their status. That knowledge changes people's behavior; many who learn that they are HIV-positive behave more carefully, and they can act on the information to save themselves and their family members. Isn't this the most important human right of all?

Quick and reliable saliva and blood tests, which give results within 20 minutes, are available, increasing the opportunity for confidentiality. Some companies, such as the South African diamond giant DeBeers SA and its affiliated mining company, Anglo-American Corp., have started to strongly encourage testing, using these quick and confidential methods. But governments have been slow to use the tests. In an important breakthrough, three small countries in Africa -- Botswana, Malawi and especially Lesotho -- recently moved from purely voluntary testing to what is called "opt-out": Testing becomes routine in certain circumstances unless the patient opts out by refusing to be tested.

This seemingly small change has had immediate results. Testing has increased dramatically. And with increased testing has come increased awareness, less stigma, safer sex practices and more people on treatment. Without question, a reduction of the prevalence of HIV-AIDS will follow. Yet the great and influential international organizations fighting AIDS have not yet, for the most part, embraced "opt-out" as part of their core strategies.

On this World AIDS Day, many empty words and promises will be heard. I am gratified that additional money will be pledged and, as a result, more lives saved. But unless the current, failing strategy is changed, we will have to spend even more money later, to treat AIDS victims who might never have been infected had testing been more widespread. Numbers don't lie: Everyone agrees that the number of people infected is still growing sharply, and not just in Africa. Widespread testing is not a single-bullet solution -- there is none -- but without knowing who is HIV-positive and who is not, there is no chance we can win this war.

The writer, a former U.S. ambassador to the United Nations, is president of the Global Business Coalition on HIV/AIDS, a nongovernmental organization, and writes a monthly column for The Post.


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