“dying with AIDS” in the rest of the world (for those who did not have access to ART). In the next section, I will discuss the socioeconomic implications that these changing cultural models have had and will continue to have in the future.
In recent years an effort has been made to make these life-saving drugs more widely available to all. Today ART is considered “standard fare” in HIV treatment and is often made available for free (via a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria). Even so, by 2008 only 13 percent of those who needed it had access to ART in Nepal (USAID 2008). So, even though ART is now “available” free of charge in Nepal, there are still structural problems preventing access for all. And in 2011 the Global Fund announced an acute funding crisis, which may limit the fund’s ability to continue providing these ART drugs free of charge in the near future (Boseley 2011).
2.1.2.2 ART as prevention
In 2011, a study conclusively confirmed what had long been suspected: that treating HIV-positive persons with ART would significantly reduce their chances of transmitting HIV to their sexual or drug-using partners. This landmark study (Cohen et al. 2011) concluded that ART treatment of an HIV-infected partner reduced the risk of transmission to the uninfected partner by 96 percent. Thus, the study definitively proved that early HIV treatment with ART has a “profound prevention benefit” (CDC 2013). The practice of treating HIV-infected persons as a method of reducing transmission came to be considered “treatment as prevention” (CDC 2013). Science Magazine hailed the discovery as the “breakthrough of the year” (Cohen 2011:1628).32
The discovery instantly worried some that it might be hailed as a kind of “magic bullet” and that future prevention efforts might therefore favor an overdependence on treatment-based prevention efforts (to the exclusion of all other prevention efforts). Soon after the announcement, well-known HIV and AIDS researchers Edward Green, Allison Herling Ruark, and Norman Hearst commented:
This week, the United Nations General Assembly meets to discuss progress against the HIV and AIDS epidemic amid news that antiretroviral drugs can drastically reduce HIV transmission from infected to non-infected partners. The U.N.’s AIDS agency, UNAIDS, has already called this news a “game changer” and at this week’s meeting will doubtless call for massive infusions of donor funding in order to implement this treatment-as-prevention approach.
Nearly as certain is that little will be said about investing in programs to encourage the kind of fundamental behavior change, particularly faithfulness between sexual partners, that has already saved millions of lives worldwide. Serious investment in such programs would cost a tiny fraction of the vast sums required for HIV treatment. Yet there is a serious lack of political will to invest in simple, low-cost programs which address the real drivers of the HIV epidemic, such as multiple sexual partners. (Green et al. 2011)
It seems that these words were almost prophetic as the discovery was “translated rapidly into policy for the global response” (Cohen et al. 2012:1439). The announcement created a firestorm of debate among HIV researchers, which is still raging as of this writing. At the heart of the debate seems to be a concern over resources. Some fear that already-limited resources (currently thinly spread over a variety of non-treatment prevention approaches) will be further appropriated from these approaches (such as behavioral change), to be spent more heavily on this new “treatment as prevention” drug-based method. And the concern seems warranted. In 2003, U.S. President George W. Bush initiated the President’s Emergency Plan for AIDS Relief (known as PEPFAR), a program that committed 15 billion dollars over five years (2004–2008) to be used globally to fight HIV and AIDS. The plan allocated 80 percent for treatment and care (e.g., ART delivery) and 20 percent for prevention (e.g., sexual behavioral change efforts). In 2008, PEPFAR was renewed by Congress, shifting emphasis toward “expanding existing commitments around service delivery” (i.e., treatment) and removing the 20 percent funding allocated for prevention altogether (Moss 2008). The debate, pitting behavior-change prevention efforts against other methods (e.g., treatment as prevention, condom distribution, etc.), is not new and it seems to be indicative of a possible ideological divide among HIV and AIDS researchers.33 And it is difficult to assess what the final repercussions of this funding shift will produce.
2.1.2.3 Limitations of ART
One of the first limitations to ART as prevention is that subsequent studies have shown far more modest results. A study published in The Lancet in 2012 (Jia et al. 2012) found that ART used to prevent HIV transmission in serodiscordant couples in China produced a far more modest reduction of 26 percent.34 While certainly significant, the results are far from the 96 percent findings of the earlier study, suggesting that while ART as prevention is a positive step forward, it alone may not be the silver bullet researchers had hoped it would be.
Many field-based anthropologists working in developing countries seem to have a less-than-optimistic view about the ability of ART (i.e., treatment as prevention) to completely solve the AIDS problem. Fauci, in an earlier article (Fauci 2011), had conveyed great optimism that ART would be the final answer to the pandemic. In a follow-up to the article, Jonathan Imbody, the Christian Medical Association Vice President for Government Relations, asked Fauci directly about the remaining barriers to ART delivery and compliance (Christian Medical and Dental Association 2011). When questioned about the challenge of getting AIDS patients to adhere to their medicines, Fauci “acknowledged the need noting, ‘we have to do behavioral intervention along with the biological.’” Imbody then went on to list various reservations that a number of individuals and organizations working with AIDS patients in developing countries had expressed to him. These included issues related to (1) motivation. “Those who haven’t yet experienced the symptoms may be less motivated and disciplined in treating the disease”; (2) stigma, which inhibits some from seeking treatment; (3) money. Because of cutbacks, some who began receiving treatment free under PEPFAR have now lost, or will soon lose free access as noted previously; (4) adherence. Non-adherence can create future drug resistance, which could be disastrous; and (5) mistrust. Testing and treatment depend upon the acceptance of science and scientists, and many individuals in developing countries do not trust either.
Many of these same concerns are relevant to the Nepali context as well. And there are certainly many other structural issues still inhibiting ART delivery in Nepal (even though it is, for now, still free). These will be elaborated on in the next chapter. So while the amazing development of ART as treatment and prevention is obviously very substantial in the global fight against HIV and AIDS, it may not be the panacea that some have made it out to be. Given the new emerging data, coupled with the limitations noted above, it would seem prudent (and responsible) for HIV researchers and the media to curb their excitement and communicate publically that, in light of the new studies and the remaining identified barriers, our approach to HIV prevention needs to remain “both/and” (i.e., treatment as prevention and behavioral change), not “either/or.”
Fortunately, there seems to be an emerging understanding concerning the limitations of any future total dependence upon treatment as prevention.35 The CDC (2013) concludes, “treatment by itself is not going to solve the global HIV epidemic” but that “controlling and ultimately ending the epidemic will require a combination of scientifically proven HIV prevention tools.” And in a recent review of its current PEPFAR plan, the Institute of Medicine (IOM) concluded the following:
To contribute to the sustainable management of the HIV epidemic in partner countries, PEPFAR should support a stronger emphasis on prevention. The prevention response should prioritize the reduction of sexual transmission, which is the primary driver of most HIV infections, while maintaining support for interventions targeted at other modes of transmission. (IOM 2013:723)
It would seem that another pendulum shift may be close at hand. It is critical to once again reassert the importance of prevention in the overall equation in order to eliminate HIV and AIDS. Such a shift would be an important and necessary correction on the part of policy planners.
2.1.2.4
