# Presentation: 162930

## Evidence That Demands Action:Comparing Risk Avoidance andRisk Reduction Strategiesfor HIV Prevention 

- The Medical Institute for Sexual Health
- Austin, Texas
*Joe S. McIlhaney, Jr., MD*
*Founder & Chairman*

##  A monograph of presentations 
addressing the HIV / AIDS pandemic
For
Ambassador Randall Tobias, 
Global AIDS Coordinator, 
and approximately 35 appointees 
of the Bush Administration 
from the White House and from HHS
Introduced by
Secretary Tommy Thompson and
CDC Director Julie Gerberding
January 8, 2004
Convened by The Medical Institute

- addressing the HIV / AIDS pandemic
- For
- Ambassador Randall Tobias,
- Global AIDS Coordinator,
- and approximately 35 appointees
- of the Bush Administration
- from the White House and from HHS
- Introduced by
- Secretary Tommy Thompson and
- CDC Director Julie Gerberding
- January 8, 2004
*Convened by The Medical Institute*

## Scientific Presentations by:

	Edward C. Green, PhD
		Senior Research Scientist at the Harvard  	Center for Population and Development Studies

	Rand L. Stoneburner, MD
		Health and Population Unit of Cambridge 	University, U.K.

	Norman Hearst, MD, MPH
		Professor of Epidemiology and Biostatistics at 	the University of California, San Francisco 	School of Medicine

- 	Edward C. Green, PhD
- 		Senior Research Scientist at the Harvard  	Center for Population and Development Studies
- 	Rand L. Stoneburner, MD
- 		Health and Population Unit of Cambridge 	University, U.K.
- 	Norman Hearst, MD, MPH
- 		Professor of Epidemiology and Biostatistics at 	the University of California, San Francisco 	School of Medicine

## Why Action?

- Worldwide, 8,000 people die of AIDS every day.
- This is the equivalent of 20 fully-loaded Boeing 747s crashing, killing everyone on board, day after day, year after year.

## Why Prevention?

- Care and treatment of HIV-infected individuals is a compassionate and, where possible, necessary action, but can have only a limited role in reversing the epidemic.

## Worldwide, Multiple HIV Prevention Programs Have Been Implemented

-   “The bulk of UNAIDS work occurs in countries struggling to respond to the epidemic.”
-   “The Programme assists governments in the development and implementation of detailed action plans to fight AIDS with a wide variety of ‘actors.’  More than 100 countries have completed such strategic AIDS plans by December 2002.”
-    Source:  Joint United Nations Programme on HIV / AIDS, 2003

## A Primary Question for PACHAon March 29, 2004

** **“Is there one place in the world, shown by scientific study, to have reversed a generalized HIV epidemic for an extended number of years?”

## The Question is Not “Does Abstinence or Does Long-Term Mutual Monogamy Work or Not Work?”

- Abstinence, by definition, eliminates risk of infection during the period it is practiced.
- Long-term mutual monogamy (faithfulness) eliminates risk unless one partner is already infected, but even that limits the number in a given group who become infected.

## The Question Is Not “Do Condoms Work or Not Work?”

-  “When used correctly and consistently, condoms are about 90% effective for preventing HIV transmission.”
- 		   			      Norman Hearst, 2004
- The majority of HIV-positive individuals are sexually active . . . Condom use at last sexual encounter ranged from 57 – 75%.
-  		          Medical Letter, CDC & FDS, 8/11/02

## The Question Is Not Vaccine

-  “For all practical purposes, UNAIDS does not believe there will be an effective vaccine in the next ten years.”
- 	      UNAIDS Executive Director Peter Piot, 2004

## The Question Is Not:

**  ****Conservative****	****	****Race****	****	****	****  Bush  **
**  ****Liberal****	****	****	****Nationality****	****	****  Kerry**
**  ****Religious****	****	****	****Community****	****  American****	**
**  ****Non-religious****	****	****Rich****	****  ****	****	****  Ugandan**
**  ****Right-wing****	****	****Poor****	****	****  ****	****  VCT**
**  ****Gay****	****	****	****	****Republican****	****  Politics**
**  ****Straight****	****	****	****Democrat****	****  ****	****  Opinion**
**  ****HIV-infected****	****	****Chinese  ****	****      Behavior change**
**  ****HIV non-infected****	****Swedish****	****      Life as usual**
**  **

## Most Importantly, The Question Should Not Be:

- Is my personal or corporate ideology or   time-honored presupposition threatened?
- Is my personal or corporate ‘prestige’ threatened?
- Is my personal or corporate financial income threatened?
- Was a program developed by me or my group of our “friends”?

## The Question for Us Is:

-  “Is there one place in the world, shown by scientific study, to have reversed a generalized HIV epidemic for an extended number of years?”
- If there is such a place, it seems to me that the obligation PACHA has is to support the implementation of that program as broadly as possible, until science shows us a more effective model.

## “When two elephants fight, the grass suffers the most.”

- “When two elephants fight, the grass suffers the most.”

- - African proverb

## People are dying, vulnerable children are being orphaned.  We must deal with the one central question.  We can deal with the other issues later if we must.

## Uganda

-   “The Uganda HIV prevention approach appears to be associated with greater communications about HIV / AIDS and people with AIDS through social networks.  In contrast, despite substantial condom use, voluntary counseling and testing, and treatment of bacterial sexually transmitted infections, other African countries have not experienced similar HIV declines or  behavioral responses.”
-                                     Rand Stoneburner, PhD, 2004

## Uganda

-   “HIV prevalence in pregnant women in Uganda decreased from approximately 30% to less than 6% from 1990 – 2000.  Similar data were observed for the general population and military conscripts.  Uganda is the only country in the world where HIV prevalence in a heterosexual population has undergone such a dramatic and sustained decline.”
-                                     Rand Stoneburner, PhD, 2004

## Confusion About Uganda’s Success

-   “Some of the confusion regarding the interpretation of Uganda’s intervention success can be attributed to reasonable caution in interpreting the complexities of HIV epidemiological and behavioral dynamics.  However, much of the confusion can be attributed to a 1997 UN publication that underrated the magnitude of the decline in casual sex from 1989 to 1995 by a factor of 7.”
-                                       Rand Stoneburner, PhD, 2004

## Uganda

-   “In Uganda, a country where a generalized HIV epidemic has been curbed, partner reduction appears to have been more important than condom use.  While condom use has recently grown rapidly in many African countries, these same countries often continue to have high levels of HIV transmission.”
-        			     Norman Hearst, MD, MPH, 2004

## Uganda

-   “There is no known example of a country that has turned back a generalized heterosexual epidemic of HIV primarily through condom promotion.”
-   “Contrary to popular belief, there is little evidence to show that all this condom promotion we’ve been doing all these years in African countries with generalized epidemics has made any difference.”
-     			                 Norman Hearst, MD, MPH, 2004

## Uganda

-   “Fortunately for Uganda, there weren’t a lot of foreign experts then telling them how to do things in the late 1980s and early 1990s.  So they did things their own way – that’s when Museveni was going around with his bullhorn telling people about “zero grazing” and, in the circles I travel (the so-called AIDS experts), everybody thought he was a clown, a buffoon.  Everybody made fun of him.  Well, it turns out he was exactly right, and we were all wrong.”
-     	                        Norman Hearst, MD, MPH, 2004

## People Could Have Been Saved

-   “According to UN projections, more than 13 million persons in sub-Saharan Africa have been infected with HIV since 1994, for a total of nearly 30 million on the African sub-continent today.  We can use these figures to calculate the hypothetical impact of a Ugandan-style intervention implemented and transferred successfully to other African countries.  If an ABC intervention had been implemented in 1996, today 6 million fewer people would be infected with HIV.”
-                                        Rand Stoneburner, PhD, 2004

## President Bush and PACHA

- President Bush introduced his President’s  Emergency Plan for AIDS Relief (PEPFAR) on January 1, 2003.
- We were there when he said that Uganda has given us a successful model, and “that is our mission and that is our goal.”
- The data which shows that he was right is far stronger now that it was then.
- PACHA’s job is to support the President by insisting that prevention efforts follow the Ugandan approach or show with credible data why they should not.
- Millions of lives depend on it.

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