Studies indicate that gay / bisexualmen who are HIV-positive have a greater number of unprotected casual serodiscordantsexual encounters than their HIV negative counterparts and are less likelyto disclosure their serostatus to their partner. There are also studiessuggesting that this may be also happening in Brazil, another country whereantivirals are widely available.
Dr. Coates emphasized that while early prevention successes of the 1980s are being eroded in developed countries, developing countries never had a chance due to the scarcity of available resources. For instance, although the US made available US $11 billion to domestic AIDS issues in 1999, it only provided US $225 million to all of Africa for the same time period. He very clearly denounced the foreign aid funding activities of the US Congress as genocidal.
Dr. Coates stated that voluntary counselling and testing is an effective HIV prevention intervention, as the number of risky behaviours decreased among HIV-infected individuals when they became aware of their status. Testing went up six-fold in Malawi when rapid testing provided same-day results as compared to the same period of time when test results took days to receive.
The logic concerning HIV-positive individuals who continue to engage in unsafe sex is simple, argued Dr. Coates, and related to care. An HIV-infected person learns of their status, receives treatment, feels better, feels like having sex, and, because care and prevention programs are not connected, engages in unsafe sexual practice because that is the community norm.
Dr. Coates criticised the US CDC for wasting money and political capital on named reporting, which he characterized as another venue of stigmatisation and discrimination against people with HIV. Continued stigma discourages testing. To defeat the stigma, said Dr. Coates, leadership in HIV prevention programs should be given to people living with HIV, and civil society should support an environment which encourages human rights.
Dr Coates concluded by declaring that society must make it safe for people with HIV so they can make it safe for society.
Tim Brown then argued that targeting just the so-called high risk populations only worked when the epidemic was small and contained. He declined to argue on the issue of scarce resources, stating he agreed that sufficient resources need to be committed to the task of HIV prevention. He pitched his presentation so as to give the best prevention advice to national decision-makers.
Four issues are moot, stated Mr. Brown: Will the policy lead to effective prevention programs, will it make the best use of all of the country's available resources, how will this advice be interpreted, and will this advice lead to unintended consequences?
He then summarized the rationale for targeting highest-risk populations.
Resources are assumed to be too limited to target everybody, there is the desire to use them most cost-effectively, and there is the assumption that by changing the behavior of one high-risk individual more new infections will be prevented.
Policies are then formulated on the model of a risk spectrum - the epidemic begins in a high-risk population then flows outward to lower-risk populations, including what he called bridge populations. This model supports the fundamental strategy of interrupting transmission at the highest risk level to slow or contain the epidemic.
He argued that there were many flaws to the model in its 'real world' use. It does not answer questions about how to 'rank' people into risk categories, and if those people can be reached. Since individual risk behaviors take place behind closed doors, and risk is not homogeneously distributed within a population, ranking is quite difficult, and that rank is not generalizable because risk behaviors may indeed be very different in like populations in other cultures. Finally, he argued, risk is a "moving target;" a person's risk behaviors are different during different times of their lives.
Highest risk populations are traditionally the most stigmatised, so implementing a policy of targeting a high-risk group may actually promote stigmatisation and discrimination. In addition, he argued, by emphasizing risk groups it allows people who do not belong to that group believe that they are not at risk.
How effective this policy will be depends on how well it covers the targeted group (e.g., clients of sex workers), which may be very difficult to access directly. In some cases, he said, it may take years to build the relationships necessary to access the intended population.
Since even the best programs reach a coverage of only about 60%, Mr. Brown said that it was necessary to more broadly target prevention efforts to include at least bridge populations and the higher risk general populations, especially including youth who generate one-half of the new HIV infections.
It is also necessary to mobilize everyone that wants to help, making the policy implementation an inter-disciplinary endeavour. He emphasized that prevention efforts for lower-risk populations need to happen earlier in order to change behaviours before the epidemic spreads extensively.
In addition, the efforts for all of the risk categories need to happen simultaneously. By the time an epidemic has become generalized, prevention efforts among the highest-risk populations will be insufficient.
Finally, addressing the issue of cost-effectiveness Mr. Brown asked if the goal was cost-effectiveness, or significantly slowing or containing the epidemic.
Cost effectiveness without coverage is a meaningless construct. He compared it to using a state-of-the-art squirt gun to put out a forest fire. Because of this, we can no longer accept cost-effectiveness as a benchmark of success for prevention policies, but shift focus to absolute prevention benefits.
Compare the cost of averting infection to the cost of treating one, then mobilize those resources in prevention efforts for all populations. Strictly targeting high-risk groups as a cost-effective measure may have such unintended consequences as inattention to cleaning the blood supply in low-risk countries because of the high cost of each infection averted. Husband-to-wife and mother-to-child prevention efforts would also not be cost-effective because wives and babies are unlikely to further spread infection.
There is no magic bullet to AIDS prevention, Mr. Brown said. Programs require strategic planning and significant commitment of resources. That they work is evidences by the successes in Uganda, Senegal, and Thailand.
In conclusion, Mr. Brown declared that there should be no question about which group prevention programs should target: countries need both approaches. The more pressing challenge is deciding how to best combine the different strategies.
The chairman's summary included points common to both debaters, including the need to incorporate HIV-positive people into the solution, rejecting the idea of resource limitation, and considering HIV prevention a human right.
In his rebuttal Dr. Coates asserted that the debate question was silly, and that new prevention strategies need to move forward. He encouraged finding the highest risk groups through voluntary testing, and to convince donors to target other groups as well.
Mr. Brown replied that HIV-positive people should definitely be part of the solution, but they cannot do it alone; both positive and negative people need to take the responsibility to make societies resistant to HIV infection.