Wednesday, July 22, 2009

AIDS Exceptionalism has Defenders

Stephen Lewis, the former UN Special Envoy on AIDS in Africa, says that "AIDS exceptionalism is a defensible concept". I have to disagree.

I think HIV is an extremely serious issue and the disease has horrifying consequences. However, I think exceptionalising it has the effect of distracting attention from the very conditions that allowed HIV to spread as widely as it has done.

Health services, education, social services, infrastructure, governance, inequalities and attitudes towards sex and sexuality are some of determinants of HIV transmission. But improvements in all these areas are necessary, regardless of whether HIV is high, low, increasing or decreasing. In Kenya, from the eighties onwards, these issues have all been ignored. The arrival of HIV as a serious epidemic didn't cause them to be ignored but it certainly provided an excuse for putting them all on the back boiler.
People need to know about safe sex, people need reproductive services and education, inequalities and prejudices need to be dealt with, but not just because of HIV. HIV is just one more sexually transmitted disease, it is just one more hazard arising from low levels of sexual health and sexual awareness.

I don't think the money going into HIV related programmes is wasted and if more money is needed, more money should be made available. But much of the money is being spent on goods and services from rich countries, very little is being spent in 'recipient' countries. These goods and services are being purchased regardless of whether that is the best strategy for HIV prevention and care programmes.

And very little is being spent on preventing new infections. Pharmaceutical and other countries are very keen to sell their overpriced products when it comes to treatment but not so keen about prevention. Yet unless the number of people becoming infected goes down, treatment will never be sustainable in the long run. Universal treatment is probably not even sustainable in the short run, for that matter.

With all due respect to Stephen Lewis, I think treating AIDS as exceptional has the effect of divorcing it from its context of serious and long term underdevelopment.

I can't comment on Lewis's accusations about other people in the AIDS field acting from motives of resentment and professional envy. I can understand if he is worried about levels of funding and how they may be affected by the current obsession with the global financial crisis. But I don't think it's justifiable to spend large amounts of money on pills for people who have no food or clean water. And I think that ridiculous situation arises in part from AIDS exceptionalism.

Communicable diseases (some of them, anyhow) get a lot more attention than other health issues but mortality from communicable diseases is only 25% of total mortality. A lot more people are dying of non-communicable conditions. More infants are dying now, more under fives are dying and more mothers are dying now, mostly from non-communicable conditions, than in the 1980s.

If Lewis believes that development funding is too low, I can agree with that. And certainly, HIV related funding has never been high enough. But there are many other diseases, communicable and non-communicable, that receive far less funding, if any. Worse still, people are dying from preventable and treatable conditions.

I don't think less money should be spent on AIDS; but I think greater amounts of money should be spent on programmes that improve people's lives more broadly rather than on programmes that concentrate narrowly on HIV, especially on sexually transmitted HIV. People's lives need to be transformed in every way and, for many, HIV is the least immediate of their problems.

When people have enough food and clean water for themselves and their dependents, when they have access to proper health services, when they receive adequate levels of education, when governance and laws actually protect people rather than increase their vulnerability, HIV treatment and care programmes may have some chance of being effective. Then also, people may be interested in protecting themselves and others against HIV.

There is a hierarchy of needs in developing countries and HIV is not at the top right now. Exceptionalising it won’t put it at the top but dealing with people's most urgent needs could raise its perceived importance.



Claire R said...

Hi Simon!
I think there is a case that HIV is an exceptional disease. However, we need to ask: will it help people to treat it as exceptional? One good reason would be if it's possible to eradicate HIV or severely hamper its spread or limit its final prevalence. Eradication is perfectly possible for polio but not for HIV; its infectious period is too long. Limiting its final prevalence would have been possible early on but is impossible now. Are there any other ways that targeting HIV at the expense of other health campaigns could help anybody? Hm. I don't think so.

Simon said...

Thanks for your comments, Claire. For a start, I'd say that there is no attempt at eradicating HIV at present, most spending is on treatment. New infections over the last few years have almost equalled the number being put on treatment.

But I think the highly polarised argument about exceptionalising HIV is a bit of a red herring. Most health related spending goes towards one disease or type of disease or narrow health issue. Spending on health systems and broader health issues, such as nutrition or water and sanitation related conditions, has been low and is falling.

The reason I feel this is a mistake with HIV is that transmission is and has always been related to factors that are not directly related to health and a lot could be achieved by advocating for changes in certain laws, calling for better policing and governance, addressing peoples' living conditions and economic circumstances, etc.

Because HIV has been hijacked by political and moral interests, even the money that has been directed to HIV, specifically, has been largely wasted. In fact, many parties concentrate almost solely on the moral and political aspects of HIV and are not even interested in the health and social problems that surround the disease.