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http://www.nytimes.com/2002/07/05/health/05IMMU.html

Modest Anti-AIDS Efforts Offer Huge Payoff, Studies Say

By LAWRENCE K. ALTMAN

ARCELONA, Spain, July 4 — Wider application of measures known to stem the spread of AIDS would prevent 29 million people in the world from becoming infected by 2010, according to two new studies reported today.

In concluding that there is overwhelming evidence that simple, relatively inexpensive steps can greatly reduce transmission of H.I.V., the AIDS virus, the reports said the number of adults infected each year would drop drastically if the measures were implemented. Some of those measures include improving the status of women, condom promotion and distribution, voluntary counseling and testing, and education programs for students and workers.

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But if countries fail to adopt the measures, about 46 million people, most in sub-Saharan Africa, China and India, would become infected by 2010, the reports estimated.

The costs of a sustained aggressive program would be $10 billion a year, or $1,000 for each infection prevented, much less, prevention advocates argue, than the cost of treating people once they become ill.

The studies began after the United Nations General Assembly special session on AIDS last year set goals of reducing the number of infected young people by 25 percent by 2005 among young people in the hardest-hit countries, and by 25 percent elsewhere by 2010. The goals can be met, said the authors of the reports, who are experienced AIDS workers from government health agencies, universities, advocacy groups and private foundations in all continents.

The reports were issued in advance of the 14th International AIDS Conference, which begins here on Sunday.

One report, by researchers from a variety of government and private groups, including the United Nations, the World Health Organization and the United States Census Bureau, is being published on Saturday in The Lancet. The researchers analyzed 86 published reports of prevention programs around the world and trends in new H.I.V. infection in 126 countries to calculate what impact prevention programs would have in each country in slowing the spread of the virus.

The second report, sponsored by the Bill and Melinda Gates Foundation and the Henry J. Kaiser Family Foundation, is a blueprint for reducing infections worldwide. That report will be discussed at the conference next week. Among other things, this report calls for efforts to improve the status of women in poor countries, which it says is central to limiting the spread of AIDS.

Though AIDS rivals history's worst epidemics, and many people have expressed a fatalistic attitude about its continued spread, "none of this is inevitable," Dr. Bernhard Schwartlander, a W.H.O. official and an author of the blueprint, said at a news conference. "We can very substantially alter the course of the epidemic if we scale up interventions rapidly and aggressively." But, he added, "there is no time to lose."

A more aggressive effort would focus on providing accurate information about how to prevent infection, because only one in five people at risk of acquiring the virus now has access to such information. For example, in China, which is on the verge of an explosive epidemic, most people do not know what causes AIDS, Dr. Peter Piot, the director of the United Nations AIDS program, said in an interview.

The blueprint is based on measures that a small number of countries have used to reduce transmission of the virus. It outlines the main steps countries can adapt to fit their own needs.

"We know what works, but we are not using it," said Dr. Helene Gayle, an epidemiologist from the United States Centers for Disease Control and Prevention. Although experts probably could have issued a similar blueprint five years ago, Dr. Gayle said, "there is a lot more evidence now for what works and what it takes to overcome obstacles to make prevention work."

A key to successful prevention efforts would be to increase the economic, legal, political and social empowerment of women to reduce their vulnerability to H.I.V., the blueprint said.

Additional measures include drugs and other steps to help prevent transmission of the virus from mother to child; education programs in the workplace and in schools, and elsewhere for dropouts; treatment of sexually transmitted infections; peer counseling for prostitutes and men who have sex with men; and programs to make clean needles and syringes available to injecting drug users.

Applying the measures would prevent a varying percentage of infections, ranging from a low of 40 percent in countries with stable or declining prevalence (like Senegal and Thailand), to a high of 70 percent in countries with rapidly growing epidemics (like Cameroon and China). Nearly a third of the benefits from the prevention measures will accrue to two countries, India and China, with an additional 40 percent in sub-Saharan Africa.

The reports emphasized that conquering AIDS requires combining prevention with treatment programs. A more aggressive effort to prevent the spread of AIDS would be far less expensive than treating those infected in an epidemic.

Money is only one obstacle to prevention, said Dr. David Serwadda of Makerere University Institute of Public Health in Kampala, Uganda. Dr. Serwadda has worked on AIDS for 20 years and was co-chairman of the group of more than 30 experts that wrote the blueprint.

For example, fewer than 5 percent of pregnant women in Uganda are able to get a drug, nevirapine, that can prevent mother-to-child transmission of H.I.V. if mothers take it during labor. The problem is not simply the drug's cost, he said, but rather the logistics of making it available to women who may not know that they are infected and most of whom deliver at home, as is the case in Uganda. These problems are greatest in rural areas.

Promoting use of condoms and programs for voluntary testing and counseling programs has worked, but more such efforts are needed in rural areas, Dr. Serwadda said.

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