When Ben Franklin counseled that “an ounce of prevention is worth a pound of cure,” he wasn’t talking about the foreskin of the penis and AIDS drugs.  Yet in 2016, Franklin’s proverb has particular relevance to both, with the global community facing the needs of the greatest number of people living with HIV ever and simultaneously hoping to end the AIDS epidemic in a generation’s time. In early June, global health leaders will convene at the United Nations for the High Level Meeting on Ending AIDS, and the balance they strike between ounces of HIV prevention and pounds of treatment will determine the arc of the AIDS pandemic. If they shortchange prevention now, their decisions will merely guarantee a future of more people needlessly infected and requiring lifelong treatment.

In medicine and public health, scientists work to ensure that diseases can be prevented from occurring, treated once they do occur, or both. Scientific advances in HIV over the past decade have proffered both curative and preventive technologies that make the end of AIDS theoretically possible within a generation’s time. To reach this goal, however, both approaches—primary prevention to protect uninfected people and drugs to treat those already HIV-infected—must be used simultaneously, without delay and almost universally.

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The Catch-22? There currently isn’t enough money to pay for both approaches at the levels required, leading to difficult trade-offs.

On the prevention front, research has shown that circumcision reduces men’s risk of HIV infection from women by 70%: protection that is almost as good as that afforded by some vaccines. Almost a decade ago, the World Health Organization recommended circumcision for men in most sub-Saharan African countries. Given the removal of the foreskin is permanent and inexpensive, male circumcision is widely regarded as the single most cost-effective approach to preventing HIV currently in existence.

On the treatment front, doctors and nurses can now harness the power of drugs to not only maintain the good health of their HIV-positive patients but also to reduce the amount of virus in their bodies to levels so low as to pose almost no risk of infecting others.  Stemming from this fact, UNAIDS defined a strategy—branded “90-90-90”—that may theoretically cut the rate of new HIV infections by 90%, if very ambitious treatment targets are reached: primarily that nearly all HIV-positive people will be diagnosed and successfully medicated before they can transmit HIV to others.  Today, however, almost half of those infected globally are unaware that they carry the virus, and HIV is very often transmitted by people before they are diagnosed. Treatment is not universally and immediately accessible, and adherence to treatment is rarely perfect. Men are far less likely to test for HIV and are diagnosed much later than women.  And… ending AIDS is not possible by testing and treating all of the women alone.

While the potential to end AIDS is astounding, actual prospects of achieving an AIDS-free generation must be tempered by the realities of human behavior, namely our reluctance to change.  This is nothing new to anyone who has followed the HIV pandemic over the past 30 years. Case in point, had people started using the common latex condom during sex 90% of the time in the 1980s, we may have ended AIDS a generation or more ago. Which is not to say that treatment isn’t vital or that condoms are the singular answer. Rather, the science of ending AIDS is not about pharmaceuticals alone, but prevention and treatment options that everyday people can and will use, and use correctly.

On the prevention front, WHO announced at the end of 2015 that 10 million men and youth had stepped forward for male circumcision, doing their part to protect themselves and end AIDS. UNAIDS in the same year revised sharply upward the male circumcision target to 27 million (additional) by 2020.  And yet the response of the President’s Emergency Plan for AIDS Relief (PEPFAR) program—the largest supporter of male circumcision for HIV prevention services to date—was to reduce their annual targets by one-third, to 2 million per year. The current PEPFAR leadership has shuttered countless circumcision clinics in a rush to abide by extant U.S. Congressional funding “earmarks” for treatment.  Yet, as the maxim goes, treatment at the expense of prevention is the most expensive option of all.  Simply stated, reducing men’s access to the very popular circumcision program is merely guaranteeing that many will instead become infected with HIV (and infect others) and require decades of treatment in the future. It’s a circular prescription for failure. If preventing HIV through male circumcision—the single most cost-effective HIV prevention strategy for the hardest hit countries—is too expensive, how can immediate and lifelong treatment for all HIV-positive people be anything but impossible? Either both prevention and treatment options are possible—an epidemiologically sound formula for balancing ounces of prevention and pounds of care—or the end of AIDS will be indefinitely postponed.


Jason Reed, MD, MPH, is an Epidemiologist and Senior Technical Advisor with Jhpiego, a global health non-profit and affiliate of Johns Hopkins University.