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Drugs alone can't curb AIDS


THE MOST widely heralded event at the recent international AIDS conference in Durban, South Africa, was the announcement that Merck, Bristol-Myers Squibb, Glaxo Wellcome, Roche and other large pharmaceutical corporations and charitable foundations would provide drugs for the treatment of HIV to poor African countries at low cost.

Unfortunately, the short-term benefits of this well-meaning gesture carry the potential threat of an even greater long-term human tragedy.

At the moment, there is no cure for HIV, nor is one expected soon. At best, existing treatment regimens only delay death from HIV. They do not prevent it. Patients who take their medications faithfully and have ready access to health facilities may live 20 years instead of 10 years, but will ultimately succumb to the virus or one of its complications.

Where drug recipients are carefully monitored to keep the amount of HIV virus in the blood and other body fluids low, and where they reduce high-risk behaviors that transmit the virus to others (as the gay community has done in the United States), there is an obvious and pressing need to ensure that all who might benefit from these drugs receive them. (Shamefully, not all in the U.S. do.)

But where infection rates are high, medical monitoring is spotty and -- most important -- high-risk practices continue, then prolonging life might be expected to increase the transmission of HIV to sexual partners and, even more tragic, to their offspring. In some countries, like Botswana, 30 percent of all sexually active adults are already infected.

In many African countries, 60 percent to 90 percent of sex workers, a group at particularly high risk of becoming infected and spreading the virus, carry the disease. Prolonging their lives without at the same time providing them with an alternative source of income and contraception only guarantees that more children will be born with HIV and ultimately succumb to AIDS. One way to avoid this unintended catastrophe is to more forcefully link treatment with effective prevention strategies that change behavior.

Affordable drugs must be but one part of a multi-pronged strategy emphasizing prevention. An analogous program, for another health problem, already exists.

The International Trachoma Initiative provides the expensive, but highly effective antibiotic, Zithromax, donated by Pfizer. But the medicine goes only to countries where its use is part of a larger program that stresses hygiene and sanitation in the control of trachoma, a disease that causes blindness.

Vigorous government programs can reduce high-risk behavior and slow the spread of HIV/AIDS.

Thailand and Uganda, two countries in which transmission of HIV was once rampant, have dramatically reduced the rates of new infections. Unless low-cost, donated anti-retroviral drugs are employed within a comprehensive program that reduces unsafe sexual practice and other high-risk behavior, we might well be extending the lives of those infected today at the cost of greater rates of infection, disease, and AIDS deaths tomorrow.

Alfred Sommer is dean of the Johns Hopkins School of Hygiene and Public Health.

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