The Presidents Emergency Plan for AIDS Relief has gotten a lot of attention recently.  Earlier this year, Congress reauthorized this monumental effort for $48 billion over the next 5 years.  This despite clamorings from several influential groups to torpedo the mission because of its lack of “prorgressive” prevention strategies and a misunderstanding of its practical successes.  However, PEPFAR has revolutionized the field of large scale emergency relief, challenging preconceptions on impact viability, and bringing a vast sea of knowledge to the long-term health systems approach to development.   

PEPFAR unashamedly brings its moral agenda to the table, challenging the liberal ideology on AIDS prevention on a scale that, at times, feels nothing short of abrasive to the modern mind.  First, there is an emphasis on abstinence, a seemingly archeic and ineffective prevention method.  And yet, from a purely scientific standpoint, this is THE ONLY effective prevention against HIV infection.  It is interesting to see the scientific field balk at its own dogma, refusing to accept its own truths.  It is also the cheapest form of prevention.  And in a time when we are all failing to do our part to meet the medical and financial demands of the developing world, we are in desparate need of cheap solutions.  Furthermore, the infrastructure is already in place.  Schools already exist.  Children have parents.  It may not be a quick solution, but in the world of HIV prevention, there is no such thing as a quick fix.  Finally, passing out condoms may decrease the risk of HIV transmission.  But the morbidity assocaited with sexually transmitted disease, teenage or unwanted pregnancy, and                   is a tide that cannot be stopped by condoms alone. 

PEPFAR also refuses to support needle and syringe exchange for IV drug users, as a form of prevention.  However, when one actually thinks about the implications of such a program in the developing world, especially the rural communities so desparately in need of assistance, hypocrisy clearly presents itself.  The mantra of health care delivery, which has captured the imagination of our national eye, has always been the core challenge of global health.  And how can we possibly propose to implement a delivery system for needle exchange programs in remote areas of the developing world, while at the same time claiming that we dont have the infrastructure to implement basic sanitation, immunization, agricultural or nutrition delivery systems in the same remote areas?  Is an immunization delivery system really more complex than a needle exchange delivery system?  Of course not.  And which will save more lives,  giving needles to IV drug users, or giving immunizations to children.  The same applies for mosquito nets, water projects, basic sanitation, hygeine education and so on.  It would border on criminality to implement a needle exchange program, while diarrhea from poor sanitation kills millions of children each year.  Furthermore, needle exchange programs are population-specific in much of the developing world.  The average farmer living in poverty in rural Africa is not an IV drug user.  It targets the urban environment, and when it comes to AIDS we cannot afford (literally) to be population specific.  Finally, while needle exchange may decrease the risk of HIV transmission, it does not decrease the other social and health risks associated with IV drug use:  commercial accidents, domestic abuse, death from overdose, death from adverse drug effects, lost time, lost jobs, lost land, and broken families to name a few examples.  How can we justify spending precious dollars to encourage such an activity when we cant even afford to provide the world with clean water?

The real fear here is personal responsibility.  This is a stigma association in the world of AIDS.  Personal responsibility implies that people are resonsible for their disease.  And these days, it is much more popular to blame HIV on poverty, corruption, crime, social segregation, racism, and lack of education.  Don’t get me wrong, these are responsible for HIV.  The studies and the evidence overwhelmingly support this.  But the world must come to terms with the idea that we are the solution to all of our problems.  Once we understand that we can prevent HIV by being intelligent and responsible, that we can prevent global warming by being diligent and careful, that we can prevent starvation by being resourceful and sharing, then the world can move forward to end these epidemics.  But until then, we’re merely treading water. 

How do we embrace this responsibility?  Education.  People can’t take responsibility for AIDS prevention in their own lives if they dont know that sexual promiscuity and IV drug use inevitably lead to HIV infection.  This they must be taught from day one.  People must be educated in order to be eligible to take responsibility.  

Furthermore, personal responsibility does not rest only in the hands of the at-risk.  They are at risk for a reason.   Social and political forces have conspired to put them in a place where they are not educated, where they do not have adequate resources (preventative or curative), and they become victims of their environment.  And that is where the developed world must embrace its own responsibility.  It is our responsibility to educate.  Not to provide an alternative or a way around personal responsibility.  Rather to provide the means to accept personal responsibility.  This is what PEPFAR has elected to do by using a small percentage of its funding to support organizations which teach abstinence and discourage drug use.  This must be a vital part of any long-term solution.  HIV prevention must be built from the ground up and the cornerstone is prevention.