At Christine Gorman‘s suggestion, today a number of global health and health bloggers around the world will simultaneously post on their blogs something broadly related to the general theme of the “Prevention vs. Treatment” debate. Although the prevention debate has more or less been silenced with regards to the HIV/AIDS debate (wow, I can’t believe I have been at anything long enough to want to say stuff like “back in the day”), I thought the recent announcement of Mark Dybul’s “resignation“, the recent reported increase in HIV incidence in Uganda, as well some of my own research made me think that this debate was perhaps worth revisiting.

In reality while the debate of “prevention vs. treatment” in the context of HIV/AIDS has been more or less quiet in recent years, it was never fully resolved. While both treatment and prevention efforts have been scaled up remarkably in many developing countries, it has been much easier to quantify or measure the impact of treatment programs, and much more difficult to measure the impact around prevention. There is not even agreement that prevention efforts have worked, and a lot of skepticism if they have worked at all. Plus, prevention efforts of some donors (those that shall not be named) have so politicized the debate around prevention, that it has become much easier to focus on the benefits of treatment rather than the benefits of prevention. Perhaps, even, at the expense of prevention.

I am going to argue, that I think the focus (warranted or not) on treatment seen in recent years, has actually prevented more rigorous debate and evaluation of prevention efforts for HIV/AIDS. Whereas treatment is a much easier intervention to conceive, with more or less guidelines easy to guidelines and protocols (although admittedly still hard to implement), prevention interventions are multifaceted, multidimensional, and target hard to measure and quantify things like behavior and culture. End-points are difficult to define, let alone get a sense of how they have changed.

I tried to do a detailed search on what we know works in prevention, and came up with only a handful of well controlled studies of the topic. It is not clear how well information campaigns work, whether it is better to eliminate risk or just reduce it, or what types of human beliefs drive the types of behaviors we are interested in. The only thing that seems to have gained any sense of consensus (from my naive outsider view) is that circumcision works and should be rolled out at a larger scale (again, a highly medical easy to standardized intervention). Everything else seems to be advocated – or not advocated – based on very limited sense of what really works.

I think the debate whether or should do either prevention or treatment is a false debate, because clearly we should do both. I also think that the relative ease of measuring treatment outcomes rather than prevention programs, in particular from donors, has prevented more experimentation and evaluation of what works for prevention. If I could say anything to whoever is coming in to become the new global HIV/AIDS Czar in the Obama administration is: please don’t assume we have much of a clue how to do prevention. We don’t have to choose between prevention OR treatment. There is more than enough money to go around. We need to do a better job evaluating both.

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3 Responses to “Prevention vs. Treament in HIV: Have we given prevention a chance to shine?”

  1. Jimmy says:

    I think it’s great that you’ve written about HIV prevention, which is really what drove me into public health. I think you’re right in that prevention is traditionally undersold compared to treatment. Part of that reason, in my opinion, is because there are no quick fixes; rather what’s required is a very broad system of norm changes.

    I don’t think anyone would consider that easy. Often times, however, I think that cultural change is the only way to go. Don’t let that be known widely though; I’m trying to do health and law.

  2. Lucy Yeatman says:

    I like your point that prevention is often hindered because debates surrounding it have been politicised. However, it is not only debates around prevention that are polemic. Often it is the approach that is easier to deal with that becomes the most favoured option. In the case of teen pregnancy, many would rather prevent it – even if it’s by ill-advised means – than deal with the consequences (teen motherhood and abortion).

  3. Anonymous says:

    In terms of evaluating methods, I recently read a Health Affairs article comparing the cost-effectiveness of different methods for preventing HIV in the US. It turns out that interventions for high-prevalence populations, like IV drug users, are very cost-effective – but they’re hard to do politically.

    -Liz (The Pump Handle)

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