Why Do Pendulums Have to Swing?

by Janine Schooley, PCI's VP for Technical Services & Program Development

August 6, 2008 :: Mexico City IAC

For every 2 persons starting anti-retroviral therapy (ART), there are 6 new infections. Clearly we cannot treat our way out of this epidemic….

At the first World AIDS Conferences, the discussions were all about prevention because, well, there wasn’t much else to talk about. There was no ART; there were no vaccine trials; there was only prevention. Then for years the focus became almost exclusively on treatment. At this year’s conference however, there is a lot of talk about prevention and, more importantly, there is a lot of talk about there being no one silver bullet, about the need for an integrated, comprehensive approach. Peter Piot, Director of UNAIDS, was philosophical about this development. He said that paradoxically perhaps we had to go through this process of veering from one to the other before we could finally come back to the realization that we need it all. He said that we left prevention in the dust of treatment, but that perhaps we couldn’t truly do what was needed in prevention until we had figured out the ART side of things. I don’t know about that (smacks a bit of a rationalization to me), but the change sure is welcome.

Not only are people this year talking about the need for both treatment and prevention, but thankfully, they are talking about something called “combination prevention” which means the kind of prevention that works on multiple levels, using multiple strategies, with none of them working in isolation – a larger, more systematic response that effectively combines biomedical, behavioral, and structural interventions and matches that combination to the particular situation and nature of the epidemic..

Oversimplification is out and context, finally and thankfully, is in. A new paradigm for monitoring, evaluation, and documentation of evidence will be needed and there must also be a realization that social change is messy and takes time. We need to focus more on the “how” and less on the “what” and we need to take into account the interplay between treatment and prevention. New partners in social and behavioral change will need to join the rank and file of HIV/AIDS combatants. In addition, prevention must be seen not as stopping something, not as preventing something, but actually as something more positive, allowing hope and sexuality to flourish and bringing out the best inour humanity and in our protection and promotion of health and wellbeing.

This theme of integration is winding its way through discussions about prevention of mother to child transmission (PMTCT), the need for family-centered approaches to care and support, and the need to focus on good primary health care and social protection when addressing the needs of vulnerable children. This is all music to my ears and is in keeping with my tongue-in-cheek suggestion of a new definition for the acronym PMTCT: Promotion/protection of Mother Together with Child Total health, as opposed to just stopping vertical transmission of one virus.

Someone joked that if we think in more integrated terms, perhaps we will all have less meetings to attend. There are of course many more compelling reasons why this pendulum swing is most welcome, not the least of which is that it means that we will finally have a good chance of making a dent in this still raging pandemic and do so in a way that is as cost effective and lasting as possible.