LETTER: HIV prevention

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Sen. Jim DeMint's column on the government's overseas assistance program ("Fighting HIV/AIDS," Op-Ed, May 27) makes some important points but also confuses some key concepts.

As a lead author on the recent paper on HIV prevention, published in Science, that Mr. DeMint cited, I disagree with some conclusions he draws from the article.

Our findings do not support his notion that "programs that teach drug addicts how to inject safely, and prostitutes and homosexuals how to have safe sex" have had "limited impact" in curtailing the global epidemic.

Though Mr. DeMint is correct that our article (which focuses on Africa) concludes that "reducing multiple sexual partnerships would have a greater impact on the AIDS pandemic and should become the cornerstone of HIV prevention efforts in Africa," we also affirmed, "Condom promotion is effective in epidemics spread mainly through sex work, such as in Thailand, and also, to some extent, among other high-risk groups such as men who have sex with men."

Mr. DeMint also was incorrect to conclude that "PEPFAR's original commitment to abstinence programs in Africa was on the mark." Actually, one might argue that PEPFAR, the President's Emergency Plan for AIDS Relief in Africa, wasted precious years focusing prevention efforts mainly on abstinence-based programs for youth, whereas a more effective approach in Africa would have been to emphasize behavior change - particularly partner reduction and fidelity - among adults (which is relatively inexpensive, as are sex work interventions) and to increase access to safe male circumcision.

Although the World Health Organization estimates that expanding circumcision services could prevent millions of new infections in Africa, this area remains vastly underfunded. Regarding abstinence, our article concluded that although "young people should be encouraged to delay sexual debut... most HIV infections occur among people in their 20s or older, when most are sexually active and, thus, abstinence is unlikely to have a major epidemiological impact."

I agree with the senator that "Congress has a responsibility to the taxpayer to ensure that aid to Africa is spent effectively... [T]he PEPFAR bill actually sends American tax dollars to China and Russia - two countries that both enjoy budget surpluses right now."

While PEPFAR provides relatively little funding to China and Russia, a minority of the PEPFAR "focus countries" are also relatively wealthy exporters of diamonds, oil and gold, and it is open to debate whether they require billions of dollars of U.S. foreign assistance for HIV/AIDS, as planned under the proposed reauthorization of PEPFAR.

Ultimately, the main question is not whether the United States can afford to help Africa - the proposed $50 billion is only a fraction of what's spent in Iraq - but how best to spend such funds, and where.

Presently, a very urgent priority, in addition to maintaining life-prolonging AIDS medications for those Africans in need, should be to help prevent mass starvation and improve basic health services in very impoverished countries such as Ethiopia. Thus, I concur with the senator's plea that "America can assist Africa, and we can do it responsibly."

DANIEL HALPERIN

Senior research scientist

School of Public Health

Harvard University

Boston, Mass.