If you think about it, PEPFAR was never a great idea. An ambitious, idealistic, somewhat glorious idea. But not actually a good one. There was no way we could keep expanding it forever. Now, the Obama administration has made the difficult decision that we cannot keep increasing PEPFAR budgets to keep pace with new HIV infections. We can’t treat our way out of an AIDS crisis and we just spent ten years focusing on treatment and neglecting prevention.

We ignored AIDS prevention because it was political. It involved a whole lot of things that are hard it talk about in public – homosexuality, casual sex, marriage, abstinence – almost every hot button issue in human politicos. It was a whole lot easier to keep spending money on anti-retroviral treatment than to talk about sex like reasonable adults.

And now, here we are, without the money or the will to keep expanding HIV treatment and we have no idea what prevention efforts actually work. The New York Times reported on the grim situation in Uganda, but Uganda is just the beginning. If PEPFAR’s budget is going to stay at the same level, and HIV infections continue to increase, people are going to be left without treatment.

A few countries have shown success in slowing the spread of AIDS, but we don’t really know why. Uganda took their HIV rate from around 30% to 6% in 2006, but it[‘s hard to know exactly what caused that success. Changes in cultural attitudes toward success? Increased condom use? Increased mortality of people with AIDS?  We don’t know, so we can’t replicate it.

Thailand gives us a little more hope. A national effort focused on ensuring condom use in sex industry reduced the rate of new HIV infections fivefold from 1991-1995. It’s a valuable model for countries with large sex industries. However, it only works in that one case. Thailand was not able to increase condom use in non-transaction casual sex encounters or among men who have sex with men.

We are really, really good at treating people with AIDS. We’re not good at keeping the disease from spreading. If we want to fight AIDS, that needs to change. People are going to die because of limitations on AIDS treatment. That’s the horrible truth. If we’d been paying more attention to prevention all along, there would be a lot fewer people in this position.

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