Washington Post, December 1, 2004

EDITORIAL: A Female Pandemic?

THIS YEAR an estimated 3.1 million people have died of AIDS, or roughly 8,500 people daily. An additional 4.9 million have been newly infected with the virus, with the result that more people live with HIV than live in California. The global response to the pandemic is more vigorous than it's ever been. And yet the policy mood among AIDS groups risks undermining progress.

The good news is that, in the past three years, global funding for the battle against AIDS has jumped from $2.1 billion to $6.1 billion. As UNAIDS reports in its latest survey of the pandemic, the number of secondary-school students receiving AIDS education has nearly tripled, the number of visitors to voluntary counseling and testing services has doubled, and the number of people receiving antiretroviral therapy is up 56 percent.

The bad news is that the pandemic's momentum still outstrips these efforts. Although counseling and testing are more widely available, less than 1 percent of adults ages 15 to 49 use these services. Fewer than one in 10 pregnant women are offered services that prevent HIV transmission during pregnancy and childbirth. Only one in 10 people who need antiretroviral therapy are getting it.

No technological silver bullet will be available soon. Researchers believe it will be a decade or more before there is an AIDS vaccine, and a microbicide -- a vaginal gel or foam that would protect women from partners who refuse to use condoms -- may be five years away. In the meantime, the world needs to redouble its commitment to provide resources for prevention messages, antiretroviral treatment and care for orphans. In its recent omnibus appropriations bill, Congress provided $2.9 billion for AIDS, nearly half the global total; France, Sweden and Holland have also been generous. But in the past fiscal year, Germany, Japan, South Korea and Saudi Arabia gave much less than their fair share, as measured by the size of their economies, to the Global Fund for AIDS, Tuberculosis and Malaria.

Even with more generosity, resources will always be limited. This is why the latest policy direction in the AIDS community is disturbing. Led by UNAIDS, donors are increasingly focused on women's particular vulnerability to HIV. In many poor societies, teenage brides are married off to older men who promptly infect them: Surveys in African cities find that HIV infection rates are higher among married females between the ages of 15 and 19 than among sexually active singles of the same age. Because of these horrifying data, AIDS groups are right to point out that the Bush administration's "ABC strategy" (Abstain, Be faithful, use Condoms) has limits. Most vulnerable teenage brides are faithful, but they cannot abstain or negotiate condoms, particularly since they want or are expected to have children.

Even so, the new emphasis on women may turn out to be an error. In a world of scarce resources, it makes sense to focus prevention efforts on high-risk groups: men who have sex with men, drug users, sex workers, truck drivers. It's not just that these groups are most at risk of infection; it's that they often do the most to spread it. A sex worker, for instance, can infect hundreds of people in the course of a month; targeting a prevention message at that worker is vastly more effective than targeting it at a faithful teenage bride, however awful her predicament. A central problem in AIDS prevention strategies is that high-risk groups are stigmatized, and hence often ignored; there's a great reluctance to put scarce money where it's most likely to be effective. By focusing its latest report on "Women and AIDS," UNAIDS is doing nothing to combat this tendency.

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