AIDS prevention funds debated: What is your say??

Role of abstinence key in Africa plan
By John Donnelly
Globe Staff / December 12, 2007

WASHINGTON - The most important battle today in fighting the AIDS pandemic, health specialists told a Senate committee yesterday, was stopping the transmission of the HIV virus in the first place. But with hundreds of millions of dollars in prevention money at stake in Congress, the experts couldn't agree on just how to do that.

Congress is considering a $30 billion five-year extension of the Bush administration's global AIDS plan that would roughly double the funding from its first five years. While there is bipartisan support for a second five-year commitment, one provision has sparked fire.
Backed by powerful conservative Christians and several epidemiologists, the White House wants to set aside a percentage of the money for messages promoting abstinence and sexual fidelity. But a group of global health specialists convened by the Institute of Medicine reported earlier this year that the strategy unwisely eliminated countries' flexibility to choose how to spend the money.

The United Nations estimates that 33.2 million people globally are living with HIV and that 2.5 million became infected this year.
At a hearing before the Senate Health, Education, Labor and Pensions Committee yesterday, several specialists testified that, unless the numbers of new infections drastically decrease, treatment programs will not keep pace.
In the first five years of the US program, Congress required that a third of total prevention budget be used to support abstinence; the requirement was later expanded to include initiatives promoting monogamy. A plan before the Senate, submitted by Richard G. Lugar, a Republican from Indiana, would allocate half of the prevention funds aimed at sexual transmission of the disease for abstinence and fidelity programs.

Dr. Mark R. Dybul, the US global AIDS coordinator, told the committee yesterday that he "strongly favored" Lugar's approach because evidence supports abstinence and monogamy as ways to prevent the spread of HIV. But he added that prevention strategy could change, saying "I'm not sure 50 percent [of the budget] will be needed in five years."

Other prevention strategies include trying to stop HIV transmission from mother to child at birth, promoting consistent use of condoms, and expanding programs for male circumcision, which studies have concluded is a highly effective means of reducing the risk of transmission.
Dr. Norman Hearst, a researcher at the University of California-San Francisco, told the panel that Uganda's reduction of HIV infections in the late 1980s and '90s can be attributed largely to a decrease in the number of adults having multiple sexual partners.

Hearst argued that Congress must set targets for abstinence and fidelity rates for African countries that receive US aid because plans to fight AIDS there were "put together by Western consultants" who often believe condoms should be the chief means of prevention. "A condom-first approach has never worked" in areas where sexual transmission drives the spread of the disease, he said.
But Dr. Helen L. Smits, the co-chair of the Institute of Medicine report on the US global AIDS program, said that Hearst's characterization of the plans was unfair. If there were no spending requirements, she said, countries could tailor programs to their needs. "If a country discovers it has a big program with needle-sharing [spreading HIV], they could devote all their money in one year to stamp it out," Smits said.

Senator Edward M. Kennedy, the Massachusetts Democrat who chairs the committee, indicated he, too, favored a comprehensive approach that allowed nations some flexibility for spending the prevention money.
The complexities of building prevention programs, some specialists said, have become apparent in the emerging evidence that a large number of sexual partners in Africa do not have the same HIV status - one partner is HIV-positive while the other is not.
One survey estimated that 450,000 "discordant couples" in Kenya alone fit into this category.

"This is a major challenge that frankly we don't know how to deal with," Dr. Peter Piot, executive director of UNAIDS, said after the hearing. "Condoms are critical for these couples. Marriage was not made for abstinence."
Prevention campaigns targeting these couples could include a mix of strategies, said specialists - including pledges to abstain, health counseling sessions, and consistent use of condoms.

Piot, who co-discovered the Ebola virus in 1975 in then-Zaire and who has worked on AIDS since the mid-1980s, said he still believes that fighting the virus depended on using several intervention strategies at once. "You need to combine interventions. I'm deeply suspicious of the search for a magic bullet," he said.

John Donnelly can be reached at donnelly@globe.com
© Copyright 2007 Globe Newspaper Company.