Bertozzi and Prevention

On October 20, 2008, in global health, HIV/AIDS, prevention, by Karen Grepin

The short-listing of Stefano Bertozzi by the committee appointed to select the next head of the UNAIDS, made me go back and re-read the article he and his colleagues put out earlier this year in the Lancet (Lancet 2008; 372: 831–44) summarizing the current state of HIV/AIDS prevention programs. Since significantly more attention has been given to treatment programs, the debate between treatment and prevention programs has largely fallen silent. Plus, the apparent success of efforts to scale up treatment programs, and the apparent failure of prevention efforts to make much difference (or at least show a difference), has led to the growing consensus that prevention just does not work. So I was thankful for this series in the Lancet on prevention. As the authors state:

Even after 25 years of experience, HIV prevention programming remains largely deficient.

The authors, however, argue not the prevention programs do not work, but rather prevention efforts thus far have largely been misallocated. Prevention can work, in theory, if the implementation of these programs is improved.

The failure has been the result of the fact that we fail to tailor prevention programs to country-specific level of and trends in the epidemic. Such country-specific responses are not likely to occur largely because we have not made the investments to generate adequate surveillance data to adequately plan for these programs. Ah…a man after my own heart…let’s blame it on bad data. Specifically:

…because the response to the epidemic for 25 years has been myopic, short-term, using an emergency approach to the epidemic, both nationally and globally, we have not invested appropriately in development of new methods or in generating data about the effectiveness of current methods.

I could not agree with this statement any more. It is amazing how little has been invested in gathering more data on the HIV/AIDS epidemic. How can entire billion dollar responses be built up on data largely collected periodically from pregnant women, presenting at non-random health facilities, a sample we know to be biased and incomplete (for example, what would this data tell us about men who have sex with men?)? You cannot manage what you cannot measure.

I must admit, I am not sure what to think about the effectiveness of prevention programs. I tend to be skeptical of most stuff I read, perhaps to a fault. But, I do not yet have a good handle on how effective these programs are, or even if they are at all effective. The existing literature has been far from compelling in either direction. Sadly, HIV will be around for decades to come, and even at this stage in the game, we have a lot to learn about more effective prevention programs. I agree with the authors, bring on the data!

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