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HIV is one of the most deadly viruses humankind has ever faced. But it has one weakness; it's an infectious disease that can be blocked by relatively basic measures, including:
· Using condoms and clean needles
· Protecting the blood supply
· Testing and giving antiretroviral medicine to expectant mothers
Although it's been known for years that this is how AIDS can be stopped, 30 million people worldwide have already died and 40 million people are now living with HIV. In the absence of aggressive prevention programs, it's estimated there will be at least 40 million new infections over the next decade.
However, there are a few countries that over the years have offered glimmers of hope -- they've had success in reducing the rate of HIV transmission. In addition, there are some new prevention tools that science has developed. Here's an overview:
Uganda's ABC Approach
An abstinence sign in Uganda
In 1986, Uganda became the first nation with a comprehensive HIV/AIDS prevention program. When President Yoweri Museveni learned of his country's growing HIV crisis, he started speaking out about it, and so did his government ministers.
Uganda developed the now-famous ABC program -- Abstinence, Be Faithful, Use Condoms. Top government officials repeated this message, along with the need to support and care for people with HIV. Grassroots organizations took up the cause. One major group, The AIDS Support Organization (TASO), founded by Noerine Kaleeba, organized people to care for the sick, and help educate others to prevent new infections, using songs and skits to spread the word. Today, TASO directly supports 22,000 HIV-positive Ugandans and has cared for over 80,000 since 1987. From a high of 16 percent of the population infected in 1992, only 4 to 6 percent of Ugandans are HIV-positive today.
But Uganda still faces an uphill battle. A guerrilla war in the northern areas makes HIV surveillance difficult, and thousands of girls have been kidnapped and sexually assaulted there. Of those who escaped, about 50 percent have tested HIV positive. Although the nationwide HIV prevalence numbers are declining, a September 2004 World Vision report found that prevalence in northern Uganda was 11.9 percent and rising. Another study of the Rakai district in southern Uganda suggests that declining prevalence may have more to do with death rates than successful prevention programs.
There are also reports that Uganda's prevention message has become muddled. In 2005, because of fears of inadequate quality, the government recalled millions of condoms, and shortages have been reported ever since. Lady Janet Museveni, a born-again Christian, has been publicly emphasizing abstinence more than the "be faithful" or "use condoms" messages of ABC. She organized abstinence marches, and in 2004 called for a national census to count the number of virgins in the country. Posters promoting abstinence, but ignoring condoms, have become ubiquitous in Uganda -- despite the fact that the Rakai study found evidence that while abstinence and faithfulness decreased over the last 10 years, condom use skyrocketed. Critics link Lady Museveni's emphasis on abstinence to the Bush administration's funding faith-based organizations to fight HIV. Uganda receives millions of dollars from the President's Emergency Plan for AIDS Relief (PEPFAR) each year, and the president's plan calls for one third of the money allocated for prevention to be spent on "abstinence-related" programs.
Thailand: 100% Condoms, But No Clean Needles
"Condom King" Mechai Viravaidya distributing condoms
Thailand took a very different approach to prevention but has also achieved some success. The government made a pragmatic choice to emphasize condom use early on. The 100 Percent Condom campaign -- which included signs at every sex venue that said "no condom, no service, no refund"; upgrading health services for sex workers; and holding condom competition days at schools -- is credited with reducing new infections from 140,000 in 1991 to just 21,000 in 2003. In 2004, UNAIDS found that only about 1.5 percent of Thais were HIV positive.
Although Thailand targeted the primary mode of transmission in the general population -- unprotected sex -- it hasn't focused on transmission among injecting drug users. Heroin is widely available in Thai prisons, but clean needles are not. In 1988, a mass amnesty was granted to prisoners and the HIV prevalence rate among drug users shot up from 2 percent to 40 percent in just one year and has stayed about the same ever since. Today an estimated 35 percent to 50 percent of injecting drug users are HIV positive, and about 30 percent of new infections are related to injecting drug use (as compared to only 5 percent in 1990).
Britain: Needle Exchange
Needle exchange is a key way to reduce infection among the injecting drug user population. In the mid-1980s, HIV was spreading rapidly among drug addicts in cities like Edinburgh, where in just 18 months the prevalence rate jumped from zero to 56 percent. Sir Norman Fowler, Prime Minister Margaret Thatcher's health minister, convinced the government to authorize needle-exchange programs. Transmissions among injecting drug users decreased dramatically.
Today, clean needles are widely available in the United Kingdom; 27 million were handed out in 2005 and HIV transmissions from injecting drug use accounted for only 6 percent of new infections that year. By contrast, in the United States, where federal funding of needle exchange programs is prohibited, injecting drug use was responsible for 22 percent of infections reported in 2003.
Brazil: Averting A More Serious Epidemic
At the beginning of the 1990s, Brazil had about 1.5 percent HIV prevalence, similar to South Africa. World Bank data predicted that by 2000, 1.2 million Brazilians would be infected. Instead, Brazil's prevalence is only 0.6 percent today, while South Africa's is now over 15 percent. There are 25,000 new infections per year in Brazil (compared to 40,000 in the United States) and 600,000 Brazilians are currently infected.
What happened? In the early 1990s, Brazil began a massive and candid education campaign, which included flyers and billboards, educating sex workers about condoms, and starting needle-exchange programs. As a result, infection rates among injecting drug users and prostitutes stayed low, as did the rate in the general population. By the time treatment became available in 1996, Brazil had already achieved a low and stable prevalence rate, which made it feasible to provide a comprehensive treatment program. (Brazil was the first country to offer free antiretroviral drugs to all its citizens.)
But for Brazil, too, the battle isn't over. Two-thirds of HIV infected Brazilians don't know they have the virus. A study in The New England Journal of Medicine estimated only 20 percent of Brazil's sexually active population has been tested for HIV (as compared to about half of U.S. citizens of reproductive age), and conservative attitudes have often blocked education in schools -- only 45 percent of schools have sex-education programs.
New Prevention Tools
Part Two: Chapter Six New Challenges
Scientists are continually testing new methods of preventing HIV transmission. Some of the most recent innovations include:
Post-exposure prophylaxis [PEP], or a short course of anti-HIV drugs, has been used for more than 10 years to help protect health care workers who were accidentally exposed to the virus. PEP has been shown to reduce transmission in those people by about 79 percent, and some studies have looked at the effectiveness of using PEP after unprotected sex. But PEP is probably not feasible prevention for everyone: For greatest protection, the drugs have to be taken for four weeks. They often make people sick from side effects, and cost between $600 and $1,000.
Over the past few years, much attention has been paid to the protective effects of circumcision, which has been proven to reduce the risk of female-to-male transmission by as much as 60 percent, and from male-to-female transmission by about 30 percent. Researchers think this is because the foreskin is enriched with lots of HIV's target cells. Although scientists have sometimes been reluctant to address the issue because of the strong cultural and religious beliefs surrounding circumcision, recently a clinic in Swaziland (which has the world's highest HIV prevalence rate, and is a country where men are largely uncircumcised) began offering free circumcision and was stampeded by men wanting the procedure. Zambia has recently begun offering low-cost circumcisions to men who want them, and there too, many clinics have been overwhelmed by the response.
Microbicides are considered the most hopeful prevention tool for women who might not be able to make their partners wear condoms. In many countries, being a married woman is the leading risk factor for contracting HIV. In other countries, condom use by prostitutes is rare, because their clients won't tolerate it. For these women, scientists are trying to develop microbicides: a gel or lotion that, when applied inside the vagina, will afford some protection from HIV. Early versions of microbicides proved to inflame the vagina and actually made women more susceptible to infection, but researchers went back to the drawing board, and today five microbicides are in clinical trials.
What About Abstinence?
President Bush's Emergency Plan for AIDS Relief (PEPFAR) designates 20 percent of its funding for prevention. Of that 20 percent, one-third is required to go to abstinence-until-marriage programs. With billions of dollars involved, the long-simmering debate over the effectiveness abstinence has exploded.
"[Abstinence] we know works," Sen. Sam Brownback (R-Kan.), who helped sponsor the legislation for PEPFAR, explained to FRONTLINE. "If you're abstinent and you're faithful, we know that that's going to substantially reduce any sort of spread of this disease."
There are two kinds of abstinence education programs: abstinence-only, which teaches that sex outside of marriage should be avoided entirely; and abstinence-plus, which teaches abstinence as the best way to avoid STDs or pregnancy, but also aims to teach alternatives, including contraception and disease prevention methods, for those who cannot abstain.
But how effective are abstinence-only programs? Studies in the United States have typically measured attitudinal rather than behavioral changes and found that the programs have delayed sexual activity for teenagers by 12-18 months. But they have also found an attendant rise in sexually transmitted infections and pregnancies, according to Dr. Chris Beyrer of the Johns Hopkins School of Public Health. "The net effect is almost nothing, and that is because if people know less, they're more vulnerable," he says.
Critics argue that the abstinence-only approach imposes one culture's morality on another. "Then take all morality out of it, and then let's just deal with it on a biological basis," responds Brownback. "Does abstinence work? Does it prevent the spread of the disease?"
A recent report from the nonpartisan Government Accountability Office (GAO) suggests that on the ground, PEPFAR's funding requirements about abstinence are causing confusion and have required target countries to cut funding from other prevention programs, such as mother-to-child transmission, in order to meet the abstinence requirement.
In 2004, more than 130 public health officials, religious and world leaders and activists called for "an end to the polarising debate" and urged the international community "to unite around an inclusive evidence-based approach to slow the spread of sexually transmitted HIV." Their approach included developing community-based programs that are culturally relevant to the setting in which they're implemented and endorsed the ABC approach -- an abstinence-plus model: "All three elements of this approach are essential to reducing HIV incidence, although the emphasis placed on individual elements needs to vary according to the target population."
Dr. Peter Piot, the head of UNAIDS, says the current debate over abstinence is familiar, and somewhat ironic. "Earlier on, I would go into heated debates with colleagues saying: 'Condoms only are not the solution. You need to think of others,'" he recalls. "We've always said it's a package deal. You need the whole picture. Otherwise we won't be able to be successful."