Our Bodies, Ourselves (170 page)

A significant accomplishment of the George W. Bush administration was the creation of the President's Emergency Plan for AIDS Relief (PEPFAR; pepfar.gov), initiated in 2003. At a cost of $15 billion over five years, it massively increased the resources available to treat and fight HIV. The plan was reviewed and expanded in 2008 as the United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, authorizing up to $48 billion for prevention, care, and treatment of these diseases in low-resource settings.

While PEPFAR had some shortcomings—including a focus on abstinence-only programs as a primary prevention strategy despite a lack of scientific evidence to support the effectiveness of such programs—PEPFAR funding enabled 2 million people to access lifesaving antiretroviral treatment and provided care and support to millions more.

In low- and middle-income countries, 5.2 million people now receive treatment, a 30 percent increase over 2008, but still only 36 percent of total need. Nearly 10 million people in poor countries who are in immediate need of these lifesaving drugs are not receiving them.
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The new plan includes funding to continue the treatment for those currently receiving it and a pledge to provide treatment to 2 million more people over the next five years.
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These shortfalls suggest that demand for antiretroviral drugs (ARVs) will continually outpace supply until more attention is devoted to prevention.

The continuing rate of new HIV infections and the unlikelihood of donors and countries fully meeting the growing demand for lifelong treatment have led to a greater emphasis on prevention, including prevention of mother-to-child transmission of HIV. Of the 2.5 million children under the age of fifteen living with HIV worldwide, the great majority have become infected through the birthing process or through breast milk.
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The risk of transmission during birth can be substantially reduced by administering ARVs to the mother, beginning early in pregnancy, and to the infant during delivery and for four to six weeks afterward. If formula feeding is not feasible or safe (owing to cost, lack of access to clean water, or social stigma), a breastfed infant has the best chance of avoiding infection if the mother receives a triple-ARV regimen for at least the last third of her pregnancy and continuing throughout the breastfeeding period.

These programs have helped reduce the number of infants born with HIV in developing countries, but there is still a long way to go. Mothers are often not able to access ongoing antiretroviral treatment for themselves, with the result that they may not survive to raise their children. Follow-up efforts during and after pregnancy are critical to ensure that women who are eligible are actually enrolled in treatment programs.

Regardless of their HIV status, many women will want to or will face societal pressure to bear children, but health workers may assume that women with HIV should not have children. Activists in Namibia and South Africa have documented several cases of forced sterilization of HIV-positive women.
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In other settings, health workers may refuse to perform abortions for women with HIV based on their misperceptions of infection risk.
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Women living with HIV have the same rights to safe and affordable contraceptive and abortion services as HIV-negative women. Women with HIV also require support to be able to conceive safely if they wish to have a child and to bring that pregnancy safely to term.
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Pharmaceutical companies are increasingly testing new drugs in poor and developing countries. African and Asian women, in particular, have been recruited for HIV/AIDS medication trials—especially medications aimed at preventing vertical transmission from mothers to babies—and contraceptive treatments. While clinical trials are an important stage in the process of developing better medical treatments, it is crucial to ensure that women recruited for clinical trials are adequately informed and protected.

Human rights activists are concerned that drugs deemed too risky for testing in America are increasingly “outsourced” to India or Africa, where more lax government oversight and greater economic deprivation can lead to abuse. For these reasons, human rights activists call for greater transparency regarding the use of human subjects, increased international regulation of drug testing, better enforcement of human rights treaties (especially the Convention on the Elimination of All Forms of Discrimination Against Women), and assurances that pharmaceutical products will be made available at affordable prices for women in developing countries once the clinical trials have ended.

Globally, adult male circumcision has emerged in recent years as a promising means of protection against HIV infection. Recent evidence indicates that circumcision can reduce a man's risk of getting HIV by as much as 60 percent.
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The extent to which male circumcision also reduces the risk of sexually transmitting HIV infection to female partners remains under investigation. Several African countries have introduced male circumcision policies and programs as a new component of their existing HIV prevention strategies.
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In addition, more STI prevention approaches are actively involving men, focusing on gender and men's attitudes and practices.

Male condoms remain the mainstay of HIV prevention programs, since they are affordable and effective at preventing transmission of HIV and other sexually transmitted infections. However, the global supply of male condoms is low and in many developing countries is largely financed by donations from international entities such as the U.S. Agency for International Development (USAID). The United Nations Population Fund (UNFPA) estimated that at least 13.1 billion condoms were needed in 2005 to significantly reduce the spread of HIV, and another 4.4 billion were required for family planning purposes. In actuality, 10.4 billion male condoms were estimated to have been used globally in 2005—around 4.4 billion condoms for family planning and 6 billion condoms for HIV prevention. Only 2.3 billion condoms were donated in 2005—representing less than 15 percent of the need.
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Thus, only four condoms were available in 2008 for every adult male of reproductive age in sub-Saharan Africa.
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Although international funding for HIV treatment has grown exponentially in the past decade, funding for HIV prevention has not kept pace, in part owing to policy debates and confusion over the direction that prevention programs should take. The necessity of ensuring a sustainable supply of condoms has often been overshadowed within these debates. Meanwhile, commodity supply specialists estimate that owing to increases in the number of contraceptive users and growing demand for condoms for HIV prevention, by 2020, an estimated $424 million will be required in commodity support to satisfy the demand for contraceptives, including condoms, in donor-dependent countries. Even if donor funding were to remain at or near current levels, the shortfall would be almost $200 million annually.
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Female condoms provide another practical and effective method of HIV prevention, but they remain a neglected tool in the arsenal of HIV prevention programs. Although the female condom is available in more than a hundred countries, its use is widespread in only a small number of them, including South Africa and Zimbabwe, where concerted efforts have been made to market and promote the device.
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A recent review found that female condoms were
generally considered to be acceptable by users; however, the international donors responsible for purchasing the bulk of female condoms from the Female Health Company, the sole manufacturer of the device, uniformly cite its high price, approximately 75 cents per condom, as a key barrier to broader availability.
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In response, FHC developed the FC2 female condom at a cost reduction of at least 30 percent. Given the substantial price reductions for FC2, as well as in patented antiretroviral therapies over the past decade, the price argument is specious and suggests a failure of collective action on the part of governments and international agencies to ensure that an effective method of HIV prevention is able to get into the hands of women who wish to use this method.

Female-controlled methods to reduce the transmission of STIs and HIV have long been sought as a means to help bring the pandemic of AIDS under control. The empowerment of women to control infection transmission is an essential tool in cultures where negotiating safer sex practices may be difficult, dangerous, or even impossible.

Two forms of female-controlled protection are preexposure prophylaxis (PrEP) and genital microbicides. PrEP involves taking certain anti-retroviral medication (the drugs that people living with HIV use to manage the virus in their bodies) on a consistent basis as a means of protecting oneself against infection. A recent U.S. study of at-risk gay men found that those taking emtricitabine/tenofovir were far less likely to contract HIV. Worldwide, further studies are under way to explore the effectiveness of this method in other risk groups and using other antiretroviral medications.
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