Saturday, February 28, 2009

Universal HIV Testing and Treatment, the Latest Fashion

The philosopher Ludwig Wittgenstein spent much of his early years as a philosopher solving all the major problems of Western philosophy. So he thought, anyhow. He spent his later years trying to answer some of the questions that his earlier philosophy raised. Since his death, philosophers have moved from trying to understand Wittgenstein’s work to trying to dismiss it or trying to explain it (or explain it away). But there are still philosophical problems, and there probably always will be. I certainly hope so.

Similar claims have been made about the end of science, as if all the major scientific problems have just about been answered or soon will be. There’s also the end of history, whatever that could mean. And then there was the long held assertion that capitalism was the only way for global economics to proceed. That was until all the major capitalist economies answered the question as to what would come next: an absurd form of communism, it seems. And after that, who knows?

Well, maybe it’s just journalists and writers of a journalistic bent who still feel the need to raise such possibilities as the end of various intractable problems, for example, of development. Thus, a recent article in the New Scientist entitled “Are we about to eliminate AIDS?” This article was motivated by a much publicised article suggesting that if universal testing were carried out in all countries with endemic HIV and all those found positive were to be put on antiretroviral treatment (ART), HIV transmission would plummet and prevalence could be maintained at a very low level by 2050.

I have discussed this latter article on several occasions and I’m sure I’ll return to it, but for now, I’d like to have a look at the claims made in the New Scientist article. Right at the beginning the article claims that it would only take existing medical technology to eliminate AIDS. This highlights a major flaw in current thinking on HIV: that it is a medical problem and will, eventually, have a medical solution.

There are medical ‘solutions’ to many of today’s health problems. The biggest killer of children in developing countries is pneumonia and other lung infections. There are solutions to many economic problems. There needn’t be hunger or malnutrition in developing countries because there is plenty of food. Quite a number of medical problems don’t require medicine, they need clean water and good food. Why is a technical fix so often seen as the only way out of a problem?

The history of HIV in Kenya is just a small part of a history of processes of ‘negative development’ carried out by the Kenyan government, various business interests, foreign governments, international financial institutions and other parties. These processes are still being carried out. Members of the government are still trying to amass wealth and power as are the business interests. Foreign governments are keen on wealth as well but power is especially important to them. It’s hard to work out what international financial institutions are interested in. Their habit of screwing up the economies of developing countries is inexplicable unless they are doing it to benefit some of the wealthier countries, but I’ll have to leave that for someone else to explain.

So bringing in a technical fix, universal testing and treatment (UTT), will not reverse the effects of what has been happening in the country since independence. The technical fix will be very successful if health, education, food security, the environment, infrastructure and all other underdeveloped sectors of Kenya are also improved. But those are very big ifs. UTT will have a chance of working if Kenya is allowed to develop.

The cost of UTT is vast. The article promoting the idea is a mathematical model and it points out that the cost of not rolling out UTT is even greater, if a long term view is taken. If the cost is vast, I would suggest that those enamoured with the idea should check on conditions in Kenya that would need to be met in order to achieve universal testing alone, when in the last 15 years they haven’t even achieved 25% testing. And UTT requires testing every sexually every adult frequently, perhaps every year.

As for the millions of people who will be on ART, what about the support services they will require? Perhaps around 35% of the people who are known to require ART are receiving it. These figures are vague, but the health services are struggling to get the numbers up as it is. And all that’s needed is a crisis like the one that occurred after the elections last year and many people are back to square one.

But crises don’t come singly in Kenya. The post election crisis was followed by water, fuel, food and financial crises. Each of them affects the ability of the country to care for its sick, not just those with HIV. The country is underdeveloped, many development indicators are going in the wrong direction. This is why Kenya has endemic HIV in the first place and it is why efforts to reduce transmission have failed so far.

UTT will not fail because the idea is a bad one, it will fail because it is a solution that requires many years of development work to occur first. And if that development work is carried out, the cost of UTT will come down, too. The cost of UTT is nothing to the cost of allowing Kenya to develop in ways that have been blocked for so many decades.

But to return to the article in question, the New Scientist one, the author claims that people on ART almost never transmit HIV, even during unprotected sex. That is a very contentious claim, many would consider it a rash one to make. But if there is any truth in it, it is only true of those responding to ART who have a low enough viral load. In Kenya there are those who don’t have access to the drugs, for whatever reason, those without access to adequate nutrition, those suffering from other serious medical conditions and those who don’t take the drugs in the recommended manner, etc. They probably can still transmit HIV or will be able to soon enough.

And what is this about HIV being the only or the biggest risk from unprotected sex? Condoms can also be used to protect against unwanted pregnancy, or hasn’t the author heard of that? There are also other sexually transmitted infections, do they not count? Herpes simplex virus (HSV) is sexually transmitted, incurable and endemic in Kenya. It also increases transmission of HIV.

I applaud the people who have worked to find a cure for HIV and those who have come up with treatments. I also applaud those who put the mathematical model together showing the promise that UTT holds. I just wish they would look a bit wider than their own profession, whether they are doctors, epidemiologists, virologists or whatever. There is the whole of health, health services, development and many other things to consider if such ambitious projects are to work.

I’m glad the issue is being discussed by huge numbers of people but HIV is not just a medical or scientific problem and medicine and science do not operate in isolation from histories, cultures, societies, economies and especially, from people, their lives their ways of behaving, their circumstances and many other constraints.



voiced thots said...

u do make it sound true.i agree with you.i work in the HIV field,and while the idea is theoretically sound ,it is not faesible in kenya now.

Simon said...

Thank you for your comment. Yes, the problem is, I wonder if there is any will behind making UTT feasible. It would be great to think that something like HIV could be eradicated or reduced to a low level. But I find it hard to believe it will be done because there are many things that could be eradicated and have not been.

Take intestinal parasites, for example, it's so cheap to treat them that pharmaceutical companies are generally not interested because the medicine has been around so long, patents have expired. They can't make much money.

As many as two billion people may be infected with intestinal parasites and the cost of eradicating them is relatively low. Eradication would have major health benefits, improve nutrition, reduce absenteeism from school and work, increase ability of children to concentrate, increase their resistance to other conditions and generally make them much healthier.

But even parasite eradication requires environmental work and safe water and sanitation, better infrastructure, better education and better health services. There is the will to produce headlines about disease eradication but not about removing or alleviating the factors that result in poor health and disease.

That's why I think UTT will probably not succeed or will not succeed very well, it's just one in a long line of miraculous cures that ignore the conditions in which people live.