The New York Times - June 11, 2004
Lawrence K. Altman

The report appealed to countries to bolster prevention programs and combine them with treatment efforts. It said widespread availability of treatment programs might have an unintended consequence: instilling a false sense of security and thereby widening the epidemic.

"There was a long period where prevention and treatment were considered as opposite strategies" and "it was necessary to choose between them," said Dr. Paulo Teixeira of Brazil, one of nearly 50 people on the team representing the United Nations, private foundations and severely affected countries. But now, he added, the two approaches must be done in concert.

Unless poor countries sharply reduce the incidence of new infections, even the most aggressive treatment programs will not keep pace with the number of people who will need treatment, said Dr. Helene Gayle of the Bill and Melinda Gates Foundation, a co-chairwoman of the team.

The World Health Organization hopes to treat three million people by next year, and the Bush administration plans a $15 billion AIDS relief program, largely for countries in Africa and the Caribbean. South Africa, which has more infected people than any other country, is planning a national treatment program.

But even if the W.H.O. meets its goal, it will not be able to treat the five million new infections that now occur each year, Dr. Gayle said.

The report says a shift in prevention strategies is needed to avoid repeating mistakes made in wealthy nations. After more potent combination anti-H.I.V. drugs began to be used in rich countries in 1996, the same prevention messages were continued, even though the new therapies had made some obsolete.

"Because H.I.V. is no longer an automatic death sentence, we must anticipate behavioral shifts and explain the benefits and limits of current therapies," Dr. Gayle said.

The report calls for wide promotion of condoms, voluntary H.I.V. counseling and testing, and the use of drugs to prevent transmission of the virus from mother to child.

The team also urged more programs to change behavior that spreads H.I.V. Such programs, it said, should discourage sex at an early age; promote monogamy and sexual abstinence; and encourage safer behavior by those who inject drugs. Fewer than one in five people at high risk of becoming infected now have access to such interventions.

Often, the team said, those groups most affected by AIDS do not grasp the scale of the epidemic. In a telephone news conference, another member of the team, Dr. Salim Abdool Karim of the University of Natal in South Africa, cited one township of 200,000 people where 42 percent of pregnant women were infected, but most did not know it.

Many AIDS workers are concerned that the emphasis on treatment might be masking a retreat from prevention because treatment is generally seen as less controversial. "Prevention has tough policy issues" like condom promotion and sex education, Dr. Gayle said.

Detecting more infected people earlier and providing education about prevention should reduce the number of new infections during the 7-to-10-year period when infected people can easily transmit the virus even though they feel well, she said.

A modest increase of high-risk behavior in countries with expanded treatment programs - like a 10 percent decline in condom use - could substantially worsen the epidemic.
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