microbicides, and microfinance. These are just some of the
most promising options being examined as potential ways to
As World AIDS Day is marked Friday, some public
health experts are saying the current focus on
universal access to lifesaving antiretroviral drugs
has had an unintended effect: sidelining prevention. Without
a vaccine to stop the virus in its tracks, preventing
new HIV infections is key to controlling the epidemic.
New strategies that attempt to change the very
environment of AIDS transmission are now being
considered. A study published online Thursday in the
British medical journal The Lancet
describes how a microfinance project in South Africa cut
women's chances of domestic violence by more than
half. Abusive relationships and HIV transmission are
known to be strongly linked.
"If you address the broader risk environment,
women and communities can be quite creative in finding
solutions," said Dr. Julia Kim, one of the
Lancet study's authors.
In the study, 430 women in rural South Africa
were loaned money to start their own small businesses.
Most women sold fruit, vegetables, or clothes or
offered tailoring services. With this newfound economic and
social independence, women were no longer obligated to
remain in violent relationships.
Rates of HIV infection continue to grow, with 4
million new cases worldwide every year. The battle
continues to be waged even in countries that were
previously models of control.
Due to erratic condom use and the virus's spread
into new populations, like married women, HIV has made
a worrying surge in countries such as Thailand
and Uganda. "We need to run faster to get ahead of the
virus," said Jennifer Kates, vice president and director of
HIV policy at the Kaiser Family Foundation, an
independent U.S.-based organization that works on AIDS
Because the AIDS outbreak itself is
accelerating, so too must the public health response.
Purnima Mane, a senior UNAIDS official, estimates that
public health officials need to make long-term plans and
shouldn't expect to see a substantial decline for at
least the next two decades.
As a collection of different outbreaks, there is
no one-size-fits-all solution to the AIDS pandemic.
Only in sub-Saharan Africa is the disease
substantially hitting the general population. In the rest of
the world, intravenous drug users, prostitutes, and
gay men are at highest risk.
"You have to focus on where transmission is
actually occurring," said Kevin De Cock, director of
the HIV/AIDS department at the World Health Organization.
Surprisingly little information is available on
how most HIV infections are acquired in various
regions. Without that basic information, it is
difficult to know which interventions would be most
Even when countries do know where AIDS is
spreading the fastest, there is no guarantee they will
focus on the epicenter. In Latin America, the disease
primarily infects gay men. And in much of Russia and Eastern
Europe, it is drug users. Yet in both regions, most
resources go toward educating general populations.
"We would make quite a bit of headway if
countries acted on the information they had," Mane said.
Governments must be held accountable for their
choices, say Jim Yong Kim, an AIDS expert at Brigham
and Women's Hospital and Harvard University. Kim
advocates "prevention scores," which would rate governments
on how appropriately their AIDS dollars are being spent.
Potential solutions in the pipeline include
microbicides, pre-exposure use of antiretrovirals, and
circumcision. Microbicides under study or development
include a vaginal gel that could help women protect
themselves against HIV--which will be especially
valuable in countries where men are reluctant to use
condoms--and substances that enhance natural
vaginal defense mechanisms by maintaining an acidic pH, kill
pathogens by stripping them of their outer covering, or
prevent replication of the virus after it has entered
Preliminary trials in South Africa last year
showed that circumcised men were 60% less likely than
uncircumcised men to become infected from female
partners. New data from trials in Uganda and Kenya are due
in mid December from the National Institutes of Health
in the United States, the trials' sponsor.
Even with technological advances, experts say
there is no silver bullet. Success ultimately hinges
"It will be so disappointing if we have a new
tool but we can't deliver it," said Kim, adding that
current bottlenecks in health care need to be
addressed now if the outbreak is to be curbed.
While WHO's ambitious "3 by 5" strategy, an
attempt to put 3 million people on antiretrovirals by
2005, failed to reach its target, the urgency inspired
by the campaign did at least galvanize the global
community. Much of that drive has dissipated since the
A recent report from the International Treatment
Preparedness Coalition claimed that efforts are
stagnating, meaning that the world will miss the
UNAIDS 2010 target of treating 9.8 million people by more
than half. Kim said public health experts have an
unfortunate tendency to spend too much time in
meetings before taking action.
"While officials work on a process of getting
consensus and no one is held accountable," he said,
"poor people die." (Maria Cheng, AP)