There are moments in history when it seems both especially difficult and particularly offensive to try to weigh one collective human tragedy against another. But if the hierarchy of human catastrophe can, at the very least, be determined in lives lost day in and day out, then the HIV epidemic still ranks at the top of this era's list.
HIV/AIDS continues to kill more than 5,000 people each day -- a body count far higher than the number of individuals who have died in recent military conflicts anywhere in the world and also higher than the number of deaths attributable to any natural disaster in recent memory. Yet, HIV/AIDS no longer receives the attention it once did. It is almost as if this epidemic has been with us for so long that we have become immune to it.
HIV can be prevented. The XVI International AIDS Conference, which begins on Sunday in Toronto, will unfold in an atmosphere of magnified worldwide attention to the myriad issues surrounding AIDS, but with fewer politicians in the crowd to hear the message than there should be, and they're the ones who need to listen.
Notwithstanding the recent infusion of funds by the Gates Foundation toward the goal of a safe and effective HIV vaccine, a solution that radical is still years away. But there are measures that can be implemented almost immediately to deter HIV transmission:
Politicians should understand that religious values will not prevent millions of people who profess to adhere to those values from having unprotected, non-monogamous sex. The promotion of condom use should not replaced by alternatives that hinge on breathtaking transformations in human nature. Condom use can prevent the spread of HIV, period.
Politicians should understand that the establishment of safe needle-exchange programs for intravenous drug abusers will not promote illicit drug abuse but will help to prevent the spread of HIV. Promotion of these programs should not be a matter of political debate, since their implementation will neither promote promiscuous sex nor illicit drug use for children of parents who impart their own family values to their offspring.
A less politically charged prevention tool has emerged with evidence that male circumcision in poor countries may help to reduce the spread of HIV. (Circumcision is thought to interfere with transmission because the foreskin contains cells that are important portals of entry for HIV into the body.) World health officials are now assessing how best to train surgical specialists to perform circumcisions in areas where the procedure is not widely available. Politicians should understand the importance of financing this training.
We also need to promote prevention research. One key initiative is the development of microbicide products that women can self-administer intra-vaginally before sexual relations to protect themselves against HIV. Many women, particularly in developing countries, understand that their sexual partners put them at risk of HIV infection and that condoms represent an effective barrier but are not empowered enough to insist that a condom be used. The study of antiviral vaginal gels and foams is now far advanced, but additional resources are urgently needed to fund the testing of these agents.
And we need further study on pre-exposure prophylaxis of HIV disease. This concept is based on the notion that the same antiretroviral drugs used to treat people after infection might also interfere with the initial HIV infection, if taken daily by individuals at high risk. Sadly, clinical studies that were to have tested this hypothesis in developing countries have now been stopped, in part because of pressure by those who thought they were being performed to benefit the drug companies that provided their drugs for testing. The likely consequence of success in clinical trials would be that such drugs would be manufactured at low cost by generic manufacturers.
These issues all fall at the intersection of clinical science, public health policy, and the ethical considerations that must guide research and clinical trial implementation. Given the status of HIV as our common enemy in the most important war that humankind is now fighting, let's hope the political will to translate scientific achievement into successful prevention efforts will prevail.
Dr. Mark Wainberg is director of the McGill University AIDS Centre and co-chair of the XVI International Conference on AIDS.
