Tackling HIV in resource poor countries

doi:10.1136/bmj.327.7423.1104

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J S Mukherjee, instructor (jmukherjee@pih.org)1,
PE Farmer, professor1,
D Niyizonkiza, research assistant2,
L McCorkle, research assistant2,
C Vanderwarker, research assistant2,
P Teixeira, head of HIV component3,
JY Kim, assistant to director general3

¹Brigham and Women's Hospital, Division of Social Medicine and Health Inequalities, Boston, MA 02115, USA
²Partners in Health, Boston, MA 02115, USA
³World Health Organization, Geneva, Switzerland

Correspondence to: J S Mukherjee, Department of Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA

Accepted 22 September 2003

Focusing on prevention of HIV will not prevent the deaths of the millions already infected. The international community must adopt a strategy that links treatment and prevention

Despite recent proposals to expand access to antiretroviral treatment for people with HIV in resource poor settings, debate continues about the cost effectiveness of prevention and treatment strategies. This debate delays the urgent action needed to implement a comprehensive global AIDS strategy. To underscore the need to link prevention with treatment, we review the effect of HIV on economic and human development, the ways in which HIV prevention and treatment are mutually reinforcing, and the requirements for scaling up the response.

Why prevention is not enough

Prevention of HIV infection is often promoted as the only feasible option in resource poor settings despite the existence of drugs to treat it. As recently as 2002, experts argued that prevention should take priority over treatment for AIDS in Africa based on cost effectiveness.1 2 However, cost effectiveness analyses fail to take into account the most important reason for implementing widespread HIV treatment–treating sick people. Prevention strategies do nothing to improve the quality or length of life of the millions of people living with HIV. Moreover, the unchecked spread of HIV is resulting in indirect costs, ranging from orphaning to famine and from stigma to professional burnout, that are damaging already heavily burdened societies.

A poignant example of the shortcomings of the focus on prevention is the practice of prioritising the use of antiretroviral therapy for prevention of mother to child transmission without giving the drugs to mothers who are sick. Although this strategy protects babies, their untreated mothers develop AIDS and die. Clearly, both prevention of mother to child transmission and treatment of HIV positive parents are needed to protect the family and community.