A New Deal in HIV Prevention: Lessons from the Global Approach

We have now entered the second decade of the human immunodeficiency virus (HIV) pandemic. Medical science has responded to this new disease with remarkable dissection of the HIV virus and equally detailed descriptions of the clinical evolution of opportunistic infections and neoplasms in patients with the acquired immunodeficiency syndrome (AIDS). An entire industry has developed to address and improve strategies for the management of patients with HIV disease. Much of the funding for HIV research in the United States has focused on the development of vaccines [1] and antiviral therapy [2]. In essence, it was (and might still be) hoped that our technology can generate a “magic bullet” to end the AIDS epidemic. Although critically important, this approach has had no immediate effect on the spread of AIDS.

An aggressive HIV prevention campaign was politically difficult, if not impossible, to initiate in the United States throughout the 1980s. Prevention of HIV requires detailed knowledge of who is at the greatest risk for disease; however, infected patients were threatened with loss of livelihood, health insurance, personal safety, and social support [3]. This social and political climate slowed our understanding of the spread of HIV and the scope of the epidemic. Although an HIV prevention campaign requires an effort to change sexual behavior, such a campaign would probably have offended and alienated some American voters. Efforts to promote condom education and use were frustrated at every level. Regardless of the clear-cut role of intravenous drug use in the HIV epidemic, drug rehabilitation programs were not expanded, and needle exchange programs …