Drastic action on HIV prevention urgently needed

Nearly 30 years after the first cases were recognized in the United States, HIV/AIDS remains an incurable disease that is devastating large swaths of our country and the rest of the world. To understand the magnitude of the destruction, look around our nation's capital. Last month, D.C. health officials announced that 3 percent of city residents had full-blown AIDS or were infected with HIV. Not only is that infection rate on a par with rates in some African countries, but the D.C. data were based only on those who have been tested for HIV; the actual rate is probably much higher. Globally, an estimated 33 million people carry the virus. In 2007 alone, about 2.7 million new infections occurred.

The annual number of new HIV infections in the United States — about 56,000 — has remained fairly constant for more than a decade. That's right, 56,000 people are infected in this country every year. Clearly, our efforts at HIV prevention have been insufficient. Drastic action and new approaches are urgently needed.

Vaccines have historically been mankind's best weapon against the worst infectious diseases. But HIV's unique and formidable nature has presented challenges to the development of an effective vaccine. Although we remain committed to the research necessary to find a preventive HIV vaccine, a licensed product is not likely to be available in the near future.

In the absence of a vaccine, three bold new approaches to controlling the HIV/AIDS pandemic are being discussed by those working in medicine and public health. These approaches are still in the conceptual and testing phases, but if applied as a group, it's possible they could have a dramatic effect.

The first approach would provide a daily dose of antiretroviral medicines to people who are not infected with HIV but are at high risk of becoming infected. This strategy, known as pre-exposure prophylaxis, or PrEP, is based on the concept that blocking HIV's replication immediately after exposure to the virus may prevent infection.

A somewhat similar strategy of treating HIV-infected mothers before and during delivery and treating their newborns for a limited time afterward has virtually eliminated mother-to-child HIV transmission in the United States.

The National Institutes of Health and other organizations are conducting clinical PrEP trials among various at-risk populations. Initial findings are expected later this year. Of course, safety and cost-effectiveness will be important factors to consider even if the approach proves effective in preventing infection.