By Richard Holbrooke
Wednesday, January 4, 2006
A month ago, on World AIDS Day, I wrote that despite all the public rhetoric about progress, "we are not winning the war on AIDS" and that the "very best that can be said is that we are losing at a slightly lower rate" [op-ed, Nov. 29]. I thought this was fairly obvious, given the fact that on each World AIDS Day since the first one 18 years ago, the number of people who are HIV-positive has increased. I thought it was even more obvious from just one stunning fact: that of the 12,000 people who will be infected in the next 24 hours around the world, over 90 percent will not learn they are sick until roughly 2013, when they develop full-blown AIDS. Meanwhile, not knowing their status, they will unintentionally spread it to other people over the next eight years, and these people will spread it to still more, and so on.
Given this situation, I suggested that current strategies are clearly not working, especially on prevention. While continuing to support increased funding for treatment of those who already have AIDS, I argued that far more emphasis should be put on detection and testing so that people learn their status and then, with counseling, change their behavior if they are HIV-positive, thus reducing the spread of the HIV virus.
This may sound simple, even self-evident, to those not involved with the issue on a regular basis, but no column I have written for this newspaper provoked a greater reaction. To listen to some of the criticism you would think I had called for mandatory testing and quarantining of people with AIDS. "This man is out of control," wrote one prominent AIDS activist under the headline, "Someone stop this man." I was accused of "championing a conservative, traditionalist public health approach, which is simply looking to identify the infected and contain them."
Such criticism ignored my strong public advocacy over the past six years of much more funding for treatment. But far more distressing were the assertions of "progress" from world leaders and editorial pages. Originally designed to put pressure on public officials, World AIDS Day has turned into an empty rhetorical ritual in which world leaders issue high-minded statements, after which they let another year of living ever more dangerously pass.
Although there were plenty of calls for more funding for treatment, so far as I am aware no one suggested new prevention strategies or even admitted that today's approaches are not working. Current policies on prevention are simple enough: Conservatives emphasize promoting abstinence (which is why a minimum of 30 percent of the American contribution to the effort is earmarked for that purpose), while liberals stress the use of condoms and the need to avoid needle-sharing. Of course, any of these practices, if followed rigorously, will prevent the spread of AIDS, but none is ever going to be used by enough people to reverse the spread of the disease. It is a classic case of American "red state-blue state" politics and ideology trumping the brutal reality on the ground, or, more accurately, in a bedroom or alleyway.
I have been told repeatedly, for more than four years, that the case for testing is not proven. But isn't it obvious that AIDS will continue to spread more rapidly as long as 90 percent of those affected do not know their status? Wouldn't greater knowledge of one's status -- held in the strictest confidence (an essential part of any testing program) -- greatly modify behavior, both for those who are HIV-positive and for the large majority who, even in the worst-hit areas, are not infected? And wouldn't the greatest beneficiaries of widespread testing be women, who are all too often helpless victims but who do not know either their own status or that of any man in their life -- and who have no way of getting their men to be tested?
Yet the dedicated and committed professional community engaged in this desperate struggle, including UNAIDS and the World Health Organization, still refuses to make testing a top priority. (One commendable exception is Randall Tobias, the Bush administration's special envoy on AIDS, who makes it a practice to be publicly tested -- if possible with a local official -- in every country he visits; he well may be the most tested person on Earth.)
Why, in general, is the issue played down? I believe it is partly a case of a mind-set that was locked in 20 years ago, at the dawn of the AIDS crisis. Stigmatization was a huge problem then, even in the United States, and antiretroviral drugs were not yet available.
But times have changed, and so has the nature of the disease and the way it is spreading. (The greatest step forward in prevention would be the development of an effective microbicide that women could self-administer, but that goal is still eluding researchers.)
Recently there has been encouraging action in three small African nations -- Lesotho, Botswana and Malawi -- which have started making testing routine and officially encouraged (but not mandatory). Lesotho's new policy, creatively called KYS, or "Know Your Status," is especially worth watching because it is a formal, widespread national effort. If it works, perhaps the high priests of the worldwide effort on AIDS will stop listening to their own echoes and unexamined assumptions -- and take action. If ever there were a place where an ounce of prevention was worth a ton of cure, this is it.
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.