It was a rare occurrence during a scientific session at an AIDS conference: a thunderous standing ovation. The enthusiastic applause at the XVIII International AIDS Conference in Vienna was in response to a presentation in which researchers determined that a microbicidal gel made with the antiretroviral drug tenofovir unambiguously cut HIV transmission by nearly 40 percent in a study of South African women.

It was a eureka moment. However, it was only the first of several studies expected over the next few years that will be needed to conclude whether microbicides made with common HIV drugs are both safe and effective as biomedical prevention approaches.

Results from a second study of tenofovir (found in the approved drugs Viread, Truvada and Atripla), either in a microbicidal gel or pill form, aren’t expected until sometime in 2013 and approval from the U.S. Food and Drug Administration (FDA) would only come many months later. Even then, it’s not clear how the gel will be recommended or paid for, and there’s another catch: The gel will only be approved for vaginal sex (rectal microbicide research is still in its infancy).

Three to five years is a long time to wait for a product that works for vaginal sex, but might not be safe or effective for two of the most common forms of HIV transmission in the United States: anal sex—the primary route of transmission in men who have sex with men (MSM)—and sharing syringes when injecting drugs.

Public health experts have another solution, though: Do a lot more of what we’re already doing.

According to HIV prevention specialists and researchers from the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta and Johns Hopkins University in Baltimore, simply ramping up current efforts by a wide margin could cut new infections by nearly half. Moreover, their study—which was published online July 14 in the Journal of Acquired Immune Deficiency Syndromes (JAIDS)—asserts that a substantial, but short-term, investment in prevention could avert hundreds of thousands of HIV infections and save the U.S. taxpayer hundreds of billions of dollars in future health care costs.

“From a technical and epidemiologic point of view, [the study is] well done and as solid a set of calculations as could be made,” says Walt Senterfitt, PhD, RN, MPH, an epidemiologist and the cochair of the board of directors of the Community HIV/AIDS Mobilization Project (CHAMP).

The CDC and the Obama administration are earning praise from some unexpected quarters for publishing these estimates, which, along with the July release of the National HIV/AIDS Strategy (NHAS), demonstrate a new willingness to heed community recommendations and to give the community the tools it needs to argue persuasively for more resources. The NHAS demands that prevention resources be targeted where the need is greatest—among MSM and black women—and calls for an exploration for how social circumstances such as poverty, stigma and incarceration exacerbate disparities in health by race, sexual and gender orientation and economics. What’s more the NHAS calls for a 25 percent reduction in new infections by 2015, and the new study says we can do even better.

While the published projections make a strong economic and scientific case for increasing HIV prevention funding, they don’t necessarily make it any easier to ask Congress—and the American people—to invest $1 billion more into HIV prevention programs each year for the next 5 to 10 years, particularly with the risk of a double-dip economic recession looming. “That’s a hard sell, a very hard sell,” says David Munar, vice president of the AIDS Foundation of Chicago.

If there’s any hope of influencing the general public and Congress, the community might need to devote as much time and energy to the fight for increased prevention funding as it did recently to save the state AIDS Drug Assistance Programs (ADAPs), suggests Laura Hanen, the director of government relations for the National Association of State and Territorial AIDS Directors (NASTAD).

“The American taxpayer needs to be convinced that this is worth spending additional taxpayer dollars,” Hanen says. “We have to figure out a way to prioritize prevention. You can see it on the global side. You can’t treat your way out of this epidemic. With only 4 percent of our funding in HIV focused on prevention, it’s just not acceptable…or winnable.”

What Does the Study Say?

The impetus for the JAIDS study began two years ago, in the fall of 2008. At that time, the CDC had just announced its revised estimates for new HIV infections in the United States. Instead of 40,000 new infections each year, the CDC said, the number was probably closer to 56,000.

In response to this sobering revelation, U.S. Congressman Henry Waxman (D–Calif.), held a meeting of the U.S. House Committee on Oversight and Government Reform, calling on experts to explain the new estimates and to testify about what could be done to stem the tide of the U.S. epidemic. One of those who testified was David Holtgrave, PhD, an epidemiologist from Johns Hopkins University and a coauthor of the JAIDS study.

Holtgrave proposed that a rapid, five-year scale-up of existing prevention activities could cut new infections by 49 percent—from 55,400 to 27,000 new infections—over a five-year period. CDC staffers at the hearing also suggested that a robust, but slower scale-up over 10 years could cut new infections by 40 percent. Both scenarios depended on more than doubling the CDC’s annual budget, though neither spoke of different HIV prevention strategies.

The scale-up scenarios proposed by Holtgrave and the CDC simply called for doing more of the kinds of activities that health care providers, public health clinics and community-based groups already do: HIV counseling and testing, surveillance and risk-reduction activities with HIV-positive and high-risk HIV-negative people.

The new JAIDS paper draws from that congressional testimony in terms of the potential benefits of a ramped-up prevention effort. It also details, however, what might happen without additional prevention resources. The authors presented five scenarios, three of which predict what might happen with no additional prevention resources, and two based on what could possibly be achieved with a rapid influx of new money. In the three “base-case scenarios,” where no new money is added, the researchers characterized one as the best-case scenario, one as the worst, and one in between.

Five Scenarios

In the best-case scenario, in which no scale-up is added, the authors made projections based on what would happen with the numbers if the rate of new transmissions dropped significantly over 10 years, along the lines seen in some communities between 2000 and 2006. In this case, the rate of new infections would decrease from 5 new infections for every 100 people already infected with HIV, to 3.1 new infections.

On the plus side, this would reduce the number of new infections each year by 24 percent, down from 55,400 to 42,300. However, given the fact that more than 40,000 people each year would be added to the ranks of those living with HIV, the total number infected would increase by 24 percent. By 2020, the authors project that 1.37 million people would be living with the disease in the United States, up from roughly 1.1 million now.

The authors state that this scenario is optimistic. Though CDC funding has remained stable, local and state HIV prevention budgets have been slashed by nearly $200 million in the past year. The impact of such drastic cuts is unknown, but they certainly won’t help. Moreover, rates among MSM have taken a sharp turn upward in recent years.

In a somewhat less optimistic scenario, also without an infusion of money, the transmission rate would fall a bit, but the total number of newly infected people each year would stay the same: 55,400. Under these circumstances, the number of people becoming infected each year would neither increase, nor decrease, but prevalence (the number living with HIV in this country) would increase by 29 percent, to 1.427 million a decade from now. The authors state that this scenario, while optimistic, is plausible. The infection rate among MSM has climbed recently, but the rate among other groups, particularly IDUs, decreased between 2000 and 2006.

In the worst-case scenario, the rate of transmission would stay the same: For every 100 people living with HIV, five new people become infected. Under these circumstances, however, as the population of people living with HIV continues to swell, so too does the overall number of people becoming infected each year. The more people infected, the more opportunities for transmission. Thus, if the transmission rate stays the same, the total number infected each year climbs by 38 percent over 10 years, as does the total number living with HIV. Instead of 55,400 people infected each year there would be 76,600, and the total number living with HIV by 2020 would increase to 1.53 million.

It doesn’t have to get this bad, however. If the authors’ projections are correct, significant improvements are found in the two additional scenarios introduced by Holtgrave and the CDC staffers in their 2008 congressional testimony.

Granted, short of a 100 percent effective vaccine, new HIV infections will continue to occur. Compounded by the fact that HIV-positive people are living longer, thanks to the effectiveness and availability of antiretroviral therapy, the prevalence of HIV infection in the Unites States will continue to rise.

The difference between the three “base-case” scenarios and the two rapid scale-up alternatives is striking in this regard. If we scale up prevention activities over five years, the CDC estimates that prevalence will increase only 13 percent by the year 2020. If the prevention is scaled up over 10 years, prevalence grows by 20 percent. Both outcomes are better than the three base case scenarios, where HIV prevalence increases by a minimum of 24 percent and potentially as much as 38 percent.

While none of these scenarios is ideal, the authors claim that the five-year rapid scale-up plan could avert more than 300,000 new infections and save more than $100 billion in lifetime medical costs.

What Do We Do With This Information?

Irene Hall, PhD, a researcher at the CDC and the study’s first author, is discouraged by those numbers. “I think that the study shows that just maintaining what we’re doing right now will make the epidemic worse. We have an opportunity now to think about how to intervene. [But if we do nothing, then] under the best scenario we will still see an increase in the number of people living with HIV, and we need to plan for that.”

Such a plan requires asking Congress for more money—a very difficult task given that President Obama has agreed to freeze most domestic spending over the next couple of years.

Holtgrave, having testified before Congress two years ago, is no stranger to the politics of HIV prevention. Yet, when asked whom he and his colleagues had in mind when they readied the study for publication he demurred. “I can’t speak for my colleagues, but for myself, I could say that I hoped that anyone interested in the course of the HIV epidemic in the United States might be interested in such analyses.”

CHAMP’s Senterfitt congratulates the researchers for their work, but says, “I’m stuck on what we do with it.”

When the Obama administration released the National HIV/AIDS Strategy (NHAS), a document that lays out a roadmap for coordinating the domestic AIDS effort over the next five years, it offered few specifics on funding. In fact, Hanen says, “There was a strong intimation in the plan that more money for HIV prevention was not on the table, at least for now.”

Munar is skeptical that the study will garner new funding. “We assume that the data are alarming, because they alarms us,” he says, “but they’re not getting anybody’s attention outside of HIV.”

Asking Congress for money is tough. As Hanen says: “They want to know that what the next $100 is going to get them. These are questions that are very hard to answer. Prevention in general is very hard to quantify, relative to the care side.”

Moving Mountains, or Cheeseburgers

Craig Washington, an HIV-positive activist, writer and prevention program manager at AID Atlanta, is ready to battle for more prevention resources. President Obama gave Washington a shout out at the NHAS unveiling for being a model activist. And like any good activist would, Washington isn’t ready to let Obama or anyone else take a pass on funding for HIV prevention. AIDS activists, he says, need to present “a strategic and articulate indignation, an anger, a refusal to accept anything less than we deserve.”

Sean Decker, a longtime HIV-positive activist, is similarly undeterred. Responding to the release of the NHAS, he posted on his blog on POZ.com:


“We can’t be overwhelmed by the thought of a U.S. president caring about people with AIDS who live in this country; in fact, to get further funding…we have to encourage our elected officials to recognize that we live in their voting district, and that we do vote. In that regard, Barrack needs us just as much—if not more—than we need him.”


Munar takes a pragmatic view of the challenges facing prevention advocates, and he suggests that a change in tactics and message might be required. He argues that we need to look beyond the community and talk to “our parents and neighbors” in order to figure out which stories will move the American public.

“We have some of the leading behavioral scientists in the world [working in HIV],” Munar says. “I think we have to apply some of those skills sets to the attitudes, behaviors and beliefs of the American people and our decision makers. We have to treat talking to Congress like a behavioral intervention. We’ve not done that. I think we’ve got to treat this with the same kind of rigor that corporate America uses to sell cheeseburgers.”

Beyond strategy, however, is the notion that activism is often about fighting for what seems impossible. Phill Wilson, the executive director of the Black AIDS Institute, is an HIV-positive long-term survivor who has been going toe-to-toe with legislators for nearly 25 years. In a panel discussion in Vienna about the implications of the NHAS, he remarked on activists’ pessimism that new money could be found for HIV prevention.

“There have never been enough resources [in HIV], and there’s not a single initiative that began with there being enough resources,” he argued. “When Congresswoman [Maxine] Waters talked about the Minority AIDS Initiative, there was no money. People said that could not happen. But it happened because people said it was not acceptable [not to have one]. Failure was not an option.”

Get Out and Do Something

When asked what the average person living with HIV (or friends, family and other supporters) can do to advocate for more prevention resources, Munar says, “First and foremost, exercise your right to vote. Your power at the ballot box is one of the most important ways you can advance sound policy on health and a whole host of important issues.”

Munar also says you can’t just vote: You’ve got to be vocal. “Tell your local and federal officials you support HIV prevention and they should too,” Munar says.

Beyond local officials, there are also city, county, regional and state HIV planning councils. Munar recommends attending meetings and volunteering for such groups if you’ve got the time and energy.

Lastly, Munar recommends learning from and getting involved with local and federal advocacy and policy organizations. These resources will get you started:

AIDS Action
www.aidsaction.org

AIDS Foundation of Chicago
www.aidschicago.org

Community HIV/AIDS Mobilization Project (CHAMP)
www.champnetwork.org

Housing Works
www.housingworks.org

National Alliance of State and Territorial AIDS Directors
www.nastad.org

Local AIDS Service Organizations (see ASO Finder)
http://directory.poz.com/

Advocacy Hub on POZ.com
http://www.poz.com/advocacy