Letter From the Editor

Dear Readers,

You've no doubt heard the expression, "the more things change, the more they stay the same." That certainly applies to me. This summer will mark my 20th anniversary working in the HIV community. Although I've strayed a bit over the years, working with alcoholic women in jail and Houston's homeless population, I always seem to come back to what I know best. It's hard not to when so many people I know and care about are impacted by HIV.

What strikes me as most strange about my 20-year odyssey is that the truism about change applies not only to me but also to the nature of this epidemic. In the late 1980s, before there were drugs to treat HIV infection, we focused on prevention through education -- safer sex with condoms or safe sex through abstinence. Then in the 1990s, we had what in retrospect feels like the golden years. New drugs that actually controlled HIV disease were being rapidly approved, money for research was abundant, and a vaccine to cure the epidemic appeared imminent.

But now, in the new millennium, a quarter century after the first cases of AIDS were reported, the outlook is not as bright as we'd expected. While here in the U.S., we're fortunate to have the best technology and ostensibly the best health care, especially for the management of HIV infection, there are some dark spots. There is still no AIDS preventive vaccine and there probably won't be for at least 10 years, there has been a resurgence in HIV infections among young men who have sex with men, women account for approximately one quarter of all new HIV diagnoses, and more significantly, not everyone who could benefit from antiretroviral therapy has access to the drugs. The most unexpected development, and the one that brings me back to my original theme of how things stay the same, is that abstinence is once again being promoted as primary prevention. It's déj? vu for those of us who were there at the beginning.

Abstinence did not work 20 years ago and it does not work today. The result of this "policy" approach to prevention is that the great strides in HIV education and treatment that we made through the 1990s have stalled. Fortunately, a new movement among advocates from both the prevention and treatment communities is beginning to sweep the globe. Biomedical prevention is a combination of the successful elements from primary prevention directed at HIV-negative people with the effective components of secondary prevention for treating HIV-positive individuals. Put another way, antiretroviral therapy can be applied in ways other than medical management to enhance traditional prevention.

This issue of RITA! demonstrates how this synthesis between primary and secondary prevention can be accomplished. Microbicides, circumcision, and pre-exposure prophylaxis were all once the domain of primary prevention but researchers have come to understand that there are two sides to the picture: if an intervention prevents someone from getting infected with HIV, it can also prevent the spread of HIV from a positive person to a negative person or it can reduce reinfection between two positive people. The same can be said for sexually transmitted diseases, human papillomavirus, or perinatal transmission. Expanding our own notion of what constitutes HIV treatment opens the door for a much broader, comprehensive approach to managing HIV infection. Biomedical prevention facilitates this merger of the two worlds of HIV prevention and treatment.

Happy reading,

Donna Rochon, Ph.D.
Editor