Friday, December 5, 2008

A Solution to Age Old Problems?

For many years now, writers on HIV and AIDS have been warning that all infectious diseases involve a pathogen, hosts and a certain type of environment. There's no reason why HIV should be an exception to this way of analysing disease. Yet many proposed approaches to HIV relate to the pathogen, some relate to the host, but very few relate to the environment.

Antiretrovirals (ARVs), proposed vaccines and microbicides are examples of fighting HIV at the level of the pathogen. Behaviour changes such as partner reduction, treatment of other sexually transmitted infections and mass male circumcision are examples of approaches that address the hosts. The first set of interventions are highly technical and very expensive. The second set are very difficult to evaluate, slow acting and potentially expensive. Also, they are not enough on their own, they do not provide 100% protection, not even 50%.

Examples of fighting disease by improving the broad environment in which people live is probably the most long term and expensive of all. Such improvements would include better health services, education, social services, infrastructure, economic conditions, lifestyle, air quality and many other things. Such improvements are not so often discussed and even less often implemented. Of course, these don't guarantee 100% protection either, but they are all good and desirable things in themselves. They will reduce many other diseases and types of human hardship.

The question is, to what extent can the first and second kind of approach work without the third kind also being involved? Take ARVs, for example. A certain level of health service is required to test and monitor a population; other treatments are often required, too. People taking ARVs must take them every day, at the right time, for the rest of their lives. They need to change their lifestyle and their diet and, doubtless, other things.

This requires some of the very environmental conditions listed above. Of course, it requires money, but maybe the international community are thinking of providing the money, as they are so keen on technical interventions. They already provide condoms and various other supplies and services needed for prevention, treatment and care of people infected with and affected by HIV.

Which takes me back to the proposal I mentioned a few days ago to roll out universal testing and universal ARV therapy for all infected individuals. How many countries have the structural conditions that would be necessary to achieve even a fraction of what this proposal intends? The countries with the highest HIV prevalence are developing countries. That means that they have poor and declining health services, they have high disease burdens, they have low literacy, they lack a proper infrastructure!

Putting it a different way, people are poor, many live in very small houses made of corrugated metal, have no access to clean water or sanitation, collect firewood to cook basic and relatively innutritious food and I could go on, I probably will, but maybe something I have said so far is clear?

These problems all existed before HIV was identified, we know a lot about how to alleviate them, but in Kenya, many of these conditions have been getting worse for several decades. Are we going to continue to ignore them just because clever scientists have come up with a solution to one of a vast number of diseases that infect many people?

A country where such a proposal would be feasible is a country where there wouldn't be high rates of HIV in the first place. It would be a rich, developed country, where people don't depend on commercial sex for their income, where people don't have to migrate to a dangerous, all male environment for much of the year to find work, where people have proper nourishment and health services, clean water, nice houses and all the things the more prominent members of the international community probably have.

This is not to say that universal testing and ARV therapy should not be rolled out. If the international community is willing to pay for everything that would be required for this proposal to work, I look forward to an end to world hunger, poverty, disease and human degradation. In fact, if the authors of this paper can just say how they will achieve universal testing (without the use of extreme force), I'll grant them all the rest and not question them any further.



Claire said...

A nice conceptual model.

Simon said...

Well, I guess I wouldn't want to suggest that there is only one valid conceptual model here. I'm sure it will be subject to review!