Wednesday, June 24, 2009

Treatment As Prevention

An interesting discussion arose in Switzerland some months back. HIV positive people who are responding to antiretroviral therapy (ART) usually have an undetectable viral load. As a result, they are not very infectious. So discordant couples, where only one partner is HIV positive, are advised that they can enjoy a normal sex life, virtually as if neither was HIV positive.

It’s important to note that, even in countries like Switzerland, not everyone responds to ART to the extent that they have an undetectable viral load. And things can change. They need careful monitoring and advice. So this is great news for people living in countries where they get very good medical care, have good levels of nutrition, have enough money to pay for any kind of treatment and care and even have an adequate level of education to understand and discuss the implications of being in a HIV discordant relationship.

But most people don't live in rich, developed, Western countries. They are lucky to find out that they are HIV positive early enough for ART to work as well as it does in developed countries. They usually don't have access to good medical care, don't have adequate nutrition for any health status and can't afford any treatment or care, aside from the pills paid for by donor aid. And they are unlikely to have a standard of education that would allow them to follow the complex debates about sexual behaviour and lifestyle choices for HIV discordant couples and the like.

Who knows what percentage of HIV positive people on ART in developing countries are responding well and have an undetectable viral load. In most cases, nobody is checking. Things can change rapidly, like during the post election violence last year, when many people on ART were unable to get their drugs. There are stock outs, such as that experienced in Uganda on several occasions. And there is the current financial crisis, which has resulted in several countries finding that they are unable to guarantee supplies of drugs and related services, even to the minority currently on ART.

But in reality, for developing countries, the most worrying thing about the so called 'treatment as prevention' debate is that treatment is not prevention. The more people on treatment, the better, there's no doubt about that. But as more and more people are starting ART, there are still tens of thousands of people becoming infected with HIV in Kenya every year.

Treatment should support Kenya's prevention campaign but it should never become that campaign. At present, over 75% of the tens of millions of dollars being spent on HIV goes to treatment and care. 'Treatment and care', in this instance, mainly refers to drugs. Many areas of health are relevant to HIV treatment and care but once the grossly over priced pills have been paid for, there is not much left for anything else. That's why only about of third of the people who need ART at present are receiving it.

Nowhere near enough money is being spent on prevention and there is even a danger that the 'treatment as prevention' slogan could end up further skewing the way HIV funds are spent. People are being infected every day and they need education, health services, infrastructure, jobs, legal rights, equality and things like that. This is not just to do with HIV alone, it's also to do with ensuring people's human rights so they can enjoy a decent quality of life.

For too long, the development agenda has been determined by rich multinationals, such as pharmaceutical companies and the health care industry. Development has always been seen as a huge market for overpriced goods, which is why so much money goes 'into' developing countries without seeming to have much effect. It goes into the pockets of rich industrialists.

HIV treatment is vital, both for people who are already infected, those who are indirectly affected and those who are, as yet, uninfected and unaffected (if there are any of these). But prevention is also vital. And for treatment, care and prevention programmes to work properly, people need schools, teachers, hospitals, health professionals, legal protection, equality, employment and many other things.

The developing world is not populated with billions of customers; it is home to billions of extremely poor and vulnerable people. HIV needs to be prevented, not just treated.


No comments: