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Since HIV/AIDS came to worldwide attention in the early 1980s, reporting on the prevalence of infections has often been vulnerable to error. This has been true both of worldwide infection estimates—which as recently as five years ago were dramatically over-estimated by the WHO due to sampling error—as well as of false predictions that certain countries, most famously India, would soon have infection rates rivaling Southern Africa’s. Given that the UN and others in recent years have needed more often to revise their estimates down rather than up, there is sad irony in the fact that the newest CDC data on HIV/AIDS in the United States suggest that the agency has underestimated new US infections by 40 percent since the late 1990s. New US infections, once believed to have held steady at 40,000 a year, are now believed to come closer to 56,000. The agency attributes its revision to improvements in data collection, and asserts that the number of annual new infections has nonetheless remained stable since the late nineties. The UN also revealed its worldwide infection estimates last week, and likewise says that new infections have remained stable overall at 2.7 million in 2007, down from 3 million new infections in 2005. Decreases in some countries (such as Uganda and Ethiopia) have been offset by increases in others (such as China, Russia and Vietnam).

Though some are finding faint solace in the fact that new infection rates have held steady, a deeper look at the numbers shows once again that the epidemic is hitting vulnerable groups at disproportionate rates: In the US, African Americans are 11 times more likely to be HIV positive than whites, and three times more likely than Hispanics; AIDS is the leading cause of death among young African American woman; and the majority of Africans living with HIV are women.

The conclusion being drawn from the evidence is that prevention efforts have failed, but the believed reasons for that failure differ dramatically. Some blame insufficient prevention funding. Others blame prevention programs that are dictated by politics rather than by need. One commentator in the Times article, a Dr. Alcabes from Hunter College in New York, went so far as to say “it looks like prevention campaigns make even less difference than anyone thought.”

There is strong evidence to back up the first two arguments. Prevention efforts have long received significantly less funding than treatment. When the President’s Emergency Plan for AIDS Relief (PEPFAR) went into operation in 2003, 20 percent of the $15 billion budget was designated for prevention efforts. California Representative Henry Waxman likewise claims the CDC’s prevention budget has decreased by 19 percent since 2002. This neglect of prevention in favor of treatment is largely motivated by compassion for the afflicted, yet in the end it is self-defeating. Worldwide there are 33 million people infected with HIV/AIDS and 3 million receiving treatment. In the five years since its inception PEPFAR, the largest unilateral HIV/AIDS program in the world, has made treatment available to 1.7 million people living with HIV, a fabulous achievement, but one that will be dwarfed if every year 2.7 million more people get in line.

There is also a great deal of controversy surrounding how prevention dollars have been spent. The original PEPFAR bill required that 33 percent of country-specific prevention program budgets be spent on abstinence. The abstinence requirement has been widely cited as an example of how the Bush administration allows religion to bleed into state affairs. But what few recognize is that the original PEPFAR bill was passed at a time when condom distribution campaigns in Africa were unintentionally presenting AIDS as a disease of prostitutes and promiscuous people, which despite its absolute inaccuracy bred stigma against the afflicted and discouraged people from using prophylactics. However misguided, the abstinence requirement was a backlash against the ineffective condom promotion campaigns of the time. It is now broadly known that the abstinence budget requirements that have been in place for the past five years have meant that more than half of PEPFAR recipient countries have had to sponsor abstinence education in lieu of purchasing, for example, sufficient supplies of medication to prevent HIV-positive mother-to-child transmission. The PEPFAR renewal that passed through the Senate a few weeks ago with a significant budget increase to $48 billion, including funding for malaria and tuberculosis, recognizes abstinence-only requirements as a misstep. The new bill improves on its predecessor by grouping abstinence with partner reduction and fidelity initiatives—interventions that have had proven success in communities where concurrent sexual partnerships are common—under a single budgetary heading.

Even this level of budgetary control is not without controversy, and some critics suggest it will in practice have the same result, i.e. politically-motivated neglect of prevention approaches that are known to work. Yet, on a significant level the discussion is not really about funding for abstinence vs. funding for mother-to-child transmission drugs. It is about funding prevention efforts that promote behavior change and funding those that sidestep behavioral issues by focusing instead on pharmaceutical prevention options. Prominent donors in HIV/AIDS, such as Bill Gates, are responding to the UN and CDC numbers by talking about the need to step up research to find technological tools for prevention: vaccines, microbicides and pre-exposure prophylaxis, or PREP treatment. No Western figure is yet talking about partner reduction initiatives, an approach that proved effective in Uganda in the mid-1980s when that country began tackling its burgeoning AIDS epidemic, as well as within the gay communities in San Francisco and New York in the 1980s. This reticence is understandable given the controversy over abstinence education, and the equally damning evidence of how condom promotion in East and Southern Africa has contributed to AIDS denial and stigma.

And yet some believe the time has come to discuss behavior change in HIV/AIDS prevention. One of the most outspoken advocates talking about behavioral issues is Dr. Helen Epstein, author of The Invisible Cure: Africa, the West and the Fight Against AIDS. A health journalist, molecular biologist and former vaccine researcher, Dr. Epstein asserts that an effective vaccine is decades away, and may be impossible given that HIV has a number of different strains and that the virus itself mutates in the body. In a recent interview with Philanthropy Action she reiterates her belief that the world already has a model for successful prevention in Uganda’s self-styled approach to the epidemic, which married a government-sponsored “zero-grazing” faithfulness campaign with community-based health care for the victims. The one called attention to the way HIV is spread; the other encouraged compassion and care for the afflicted.

This is not to say that what worked for Uganda would work everywhere—Uganda’s approach addressed a specific cultural dynamic. What it does point to, however, is that one of the only country-specific success stories in AIDS prevention got that way by, in Epstein’s words, “grasp[ing] the nettle of sexual behavior.“ This is a lesson that could be applied elsewhere, including in the United States, where having multiple concurrent sexual partners is one suspected dynamic contributing to the over-representation of African Americans within the HIV-infected population. Within that context, requiring that prevention efforts get renewed focus and that some of the prevention budget be spent on initiatives that promote culturally-appropriate behavior change, is not evidence of cultural imperialism. It is sound, sensible policy.

Steve Feder contributed research for this post.

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