Many public health officials in the U.S. and abroad initially regarded HIV as a "gay" epidemic, so broad prevention strategies were not immediately put in place, allowing the virus to spread unchecked amongst unsuspecting segments of the population. For example, the WHO didn't establish the Global Program on AIDS until 1986 -- a full 3 years after researchers found that HIV is transmitted through bodily fluid exchange. During that period, it's estimated that the virus infected 200,000-300,000 people in the U.S. alone.
However, by the mid- to late 1980s, several HIV prevention awareness programs had been established in the United States. These programs focused on condom distribution and the rapid testing and diagnosis of STIs (including HIV) -- as well as encouraging the development of counseling programs for HIV-positive patients to stress the dangers of spreading the disease. In the U.S. and other developed countries, prevention programs primarily targeted high-risk groups, but only became highly effective when smaller, community-based initiatives were instituted. By the late eighties, community-targeted programs made a difference reducing the rates of transmission within high-risk groups in urban areas.
Other prevention initiatives, particularly in developing countries, focused on decreasing mother-to-child transmission rates,. Those programs effectively reduced transmission rates by 80-90% between 1991 to 2002 by stressing the importance of anti-retroviral therapy (ART) during pregnancy and discouraging HIV-infected mothers from breastfeeding after birth.
In 1990, the U.S. Congress passed the Comprehensive AIDS Resources Emergency (CARE) act, which provided healthcare provisions to HIV-positive Americans who were either uninsured or underinsured. Under this act, AIDS Drug Assistance Programs (ADAPS) were established to offset the high cost of anti-HIV drugs. Cumulatively, these preventative programs have led to an 88% drop in transmission rates since the discovery of HIV.
While targeted prevention programs successfully reduced transmission rates in the developed world, the implementation of effective prevention programs has been more of a challenge in the developing world. The governments of several countries have gone so far as to deny the existence of HIV within their borders. This resulted in a complete lack of prevention strategies and allowed myths and misconceptions to become widespread amongst their populations. As a consequence, HIV statistics from several countries were or are not available, meaning that their estimates of infected person estimates are far too low, -- and, most importantly, the spread of the virus has continued unchecked.
Most countries' prevention programs focus all but exclusively on providing barrier protection, but their successes are varied and often limited. With but a few exceptions, such as in Uganda, Thailand, Zimbabwe, and Kenya, these limited prevention programs have failed to contain the spread of HIV.
In the few aforementioned countries in which barrier protection promotion programs were successful, it is important to note that they focused additionally on altering sexual behavior of different segments of the population -- including but not limited to just high-risk groups -- in addition to promoting barrier protections.
Because of this, more reliable means of prevention have been sought. A 2009 study confirmed that male circumcision is 55% effective at reducing HIV transmission rates. Coupled with the fact that most people in endemic areas are not circumcised, this could be a highly effective means of cutting transmission rates by more than half. Another promising study found that participants reduced their risk of contracting HIV by 66% if an anti-HIV gel was applied every time before having sex. Even when women did not use the gel every time they had sex, their risk was reduced by 30%. However, a more recent study of an anti-HIV gel requiring daily application was halted after scientists found that the rate of HIV infection was the same as with a placebo: doctors suspect that patients "got tired" of using the gel. But even that study doesn't diminish scientists' hopes that there is a prevention measure that could decrease transmission rates in endemic areas.
As discussed in part one of this series, ART has recently been shown to be 96% effective at preventing HIV transmission if patients are put on ART immediately. However, currently only 42% of HIV-positive individuals who should be on the treatment are, and the cost of distributing ART to all patients for an indefinite period of time is extremely high.
All of the evidence gathered from effective prevention programs tells scientists and public health experts more money is needed -- lots more money. In addition to money earmarked for drug distribution programs, which currently gets the lion's share of funds internationally, it's clear that more money is required to fund effective prevention programs and healthcare infrastructure to distribute drugs, monitor patients and help educate people about the disease and provide them with the means to prevent it.
But even domestically, seventeen cash-strapped states have recently cut their ADAPs, lowering the income threshold used to qualify for the programs -- and the cost of HIV drugs are $12,000-25,000 a year per patient. Because of ever-worsening economy and high unemployment, the strain on these domestic programs can only get worse. Consequently, thousands of HIV-positive Americans have been wait-listed for the drugs that keep them healthy and reduce their risk of transmitting the disease -- and raising fears that cycling patients on and off treatment plans might create drug resistant strains of HIV.
Some states have abolished the ADAP waiting lists altogether, forcing people to turn to drug company-directed assistance programs. Those programs have a very limited amount of space and provide only temporary coverage. This begs the question: if Americans don't have the political will necessary to fund ART for low-income citizens, how are aid organizations realistically going to maintain funding for ART for all infected people in the most endemic areas?
Furthermore, the populations of several countries where AIDS is endemic have shown a widespread interest and willingness to institute programs that distribute microbicidal gels and provide access to male circumcision. However, these programs are already drastically underfunded and there is still controversy over their broad implementation.
The best bet is to take a multilayered approach to HIV prevention. While we continue to learn which public health measures are most effective at reducing and maintaining low transmission rates, consistent funding is needed to keep the fight against HIV-AIDS in forward motion -- and to bring the most assistance to the people who need it the most.
Read more of our series on the AIDS epidemic.
[Image via Mike Blyth on Flickr, Creative Commons licensed]
