Dan O'Neill

Sec Hillary Clinton Lays Out US Plan to Fight HIV/AIDS

Filed By Dan O'Neill | November 08, 2011 5:00 PM | comments

Filed in: Politics
Tags: AIDS strategy, global AIDS, Hillary Rodham Clinton, HIV/AIDS, NIH

Secretary of State Hillary Rodham Clinton visited the NIH today to give a major speech, in which she presented a new vision for the fight against HIV/AIDS. Her words tied in with upcoming December 1st Federal World AIDS Day activities and served to promote the upcoming 2012 International AIDS Conference, happening in Washington, DC this July.

HillaryClintonAIDS.jpegIn two noteworthy nods to the LGBT community, Clinton made the surprise announcement that Ellen Degeneres will serve as US State Department's New Special Envoy for Global AIDS Awareness; and later she mentioned that we will only make effective progress against HIV stigma by "repealing laws" that criminalize and discriminate against people "based on their sexual orientation."

The overarching theme of her vision was that of an "AIDS Free Generation." To achieve this goal, Clinton charged the international community to join the US government in seizing this pivotal opportunity to turn the tide in the global HIV pandemic by redoubling our efforts and funding of HIV treatment and prevention programs, focusing on a combination of evidence-based interventions that will gain the most ground. In particular, Clinton mentioned three top priorities:

  1. Reduce mother-to-child-transmission rates to "zero" (not "virtually zero," as Clinton remarked her speech writer suggested she say).
  2. Scale up rates of voluntary medical male circumcision.
  3. Scale up global provision of HIV anti-retroviral treatment.

Thankfully, she also underscored the importance of continuing support of other (very effective and far less costly) modes of prevention, including use of condoms, microbicides, and regular HIV testing in concert with these larger efforts. I often worry that in the ongoing battle among HIV/AIDS advocates over the supremacy of the HIV prevention versus the HIV treatment strategy, a battle that Clinton claimed should now be settled, we've forgotten that tried and true modes of prevention from decades past are still effective and must remain in our armamentarium. Yes, HIV treatment is effective in lowering viral loads and by extension preventing future infections. And yes, it appears that in the long-term it is cost effective to supply drugs globally to offset tremendous economic costs otherwise shouldered by countries ravaged by HIV/AIDS. However, the promising data we're getting about many new treatment-based interventions still should not trump or overshadow other, equally effective "prevention-as-prevention" modalities (e.g. condoms and good ol' education).

Clinton was quick to acknowledge the misgivings that many may have about a more treatment-focused approach to this strategy, and did well to emphasize that older, evidence-based approaches will continue to be funded along side the need for ongoing counseling. She used this opportunity to to make well-justified jab at the Right's ongoing War on Science, saying that although many in Washington still believe we live in an "evidence free zone," following science and reason is the only way we'll ever win the fight against HIV/AIDS.

Her comments about using multiple evidence-based approaches highlighted the important concept of finding the optimal mix or combination of HIV interventions to reduce new rates of infection. Already mathematical models of the combination strategy she proposed demonstrate a theoretical reduction of new rates of infection by 40-60% over a relatively rapid timeframe. Moreover, she announced that an additional $60 million of PEPFAR money is to be invested in four African countries to further study the impact of combination HIV intervention strategies to better refine our efforts moving forward. As such, she has called on other nations to now join the US in this effort to further improve our global strategy.

The top three focus strategies are good ones. Modes of reducing mother-to-child-transmission prevented an estimated 114,000 new infections last year from PEPFAR funds alone. And yet, currently 1 in 7 new infections globally continue to occur through this vertical route of infection. So there's certainly a real opportunity for large gains yet to be made on this front.

As for circumcision, since 2007 more than 1 million men have received voluntary circumcisions for prevention of HIV transmission, three quarters of which were funded by PEPFAR. This intervention is known to reduce rates of HIV infection by as high as 44% in circumcised men.

Finally, it is true that treatment is prevention, and that the cost of providing one individual anti-retroviral drugs in Africa has dramatically decreased from an average of $1100/year in 2004 to about $300-400/year today. This is encouraging news, especially for proposed expansion of funds for international anti-retroviral provisions; but I'm certainly for reducing our reliance on medication as much as possible, if we are truly to have a future generation free of AIDS.

Moving forward, Clinton said that there will be increased transparency of multinational organizations, such as the Global Fund, to weed out corruption and fraud. Moreover, countries receiving aid will be expected to ante-up, with more limitations placed on governments using their domestic funds, otherwise appropriated for public health, for other projects, offset by incoming international aid.

Clinton's speech marked an exciting recommitment to the global fight against HIV/AIDS, drawing from the recent move towards more unified strategies to fight this pandemic, as reflected by the National HIV/AIDS Strategy. Above all, these strategies aim to focus our efforts and have us succeed where we have too often failed before: in working together, despite the tendency for HIV/AIDS to divide us.

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I am very concerned by the focus on circumcision as an HIV preventative. The most optimistic figures regarding its efficacy are miles below safe-sex initiatives, on top of the ongoing concerns around the breadth and rigor of the studies that support it: http://www.futuremedicine.com/doi/full/10.2217/17469600.2.3.193

Over the last century, circumcision has been touted as the solution to whatever the big societal fear was, including masturbation, mental retardation, cancer, and now HIV.

HIV rates in the United States during a period where circumcision was common, show that the procedure is far from the "vaccine" it is often compared to, and implying otherwise provides incentives for the kind of sexual practices that further spread the disease.

From everything I've read, it seems to me that the jury is still out on the role of circumcision and HIV transmission. There are studies and counter studies, back and forth. Truthfully I'm not sure what to believe. But if they are adults voluntarily being circumcised that is something much different than doing it to a baby, who has no choice.

Does this push to end HIV going to happen here in the US as well? Because most school based sex education classes suffer from a lack of information. And thats where we need to concentrate our education efforts. A great deal of the abstinence based sex education has little to none info about AIDS and how to keep safe. Many of those programs give the kids the idea that unless your gay, there's no chance to catch it. Many of these kids also think that getting HIV is nothing, they have pills for that, so whats the big deal?

I dont know if you read many blogs of a non-political type or not. But out in the blog-o-spere there is a growing number of young gay guys who seek out HIV+ guys to have sex with, to be "breed" by them, they think the risk is hot hot hot. Who knew an entire new kink, yeah?

"It was the U.S. National Institutes of Health (NIH) that funded the three now-famous circumcision studies in Africa -- Uganda, Kenya and South Africa. NIH launched these studies after some previous studies, including one done in 1997, found no "prophylactic" evidence that circumcision is effective against HIV.

"To head the studies, the NIH tapped four men who were known circumcision advocates -- thus creating an obvious bias. These circumcision advocates were: Bertran Auvert in the South African study, Robert C. Bailey and Stephen Moses in the Kenyan study, and Ronald H. Gray in the Ugandan study. According to Doctors Opposing Circumcision, all four men have been pushing circumcision for many years, since at least 1998."

See http://www.bilerico.com/2011/08/to_snip_or_not_to_snip.php