Sunday, August 2, 2009

Healthy People Have Needs Too

The aim to roll out antiretroviral treatment (ART) for everyone who needs it was always dogged by (usually tacit) questions about sustainability. In Uganda, for example, ART is 95% donor funded. For various reasons, much of that funding is now being reviewed or cut.

Many people who are put on ART will, sooner or later, need a course of second line drugs because of resistance to the first line drugs. This increases the cost of the drugs by 6 or even 10 times. And resistance can also develop to second line drugs.

The drugs themselves are only one cost involved in treatment but as the drug companies are getting the lion's share of HIV related money, there is little pressure for money to be spent on other treatment costs. The fact that the drugs are bought, paid for and delivered to the country in question doesn't mean that the country has the capacity to distribute them and actually treat people.

But the most unsustainable aspect of aiming for universal ART rollout is that little is being done to reduce the rate of new infections. The rate of new infections continues to exceed the number of people being put on treatment.

The trend towards putting people on ART earlier may have some impact on the rate of new infections. The idea of testing everyone and treating everyone found to be HIV positive may also have an impact. And the idea of putting everyone thought to be at risk of being exposed to HIV on ART, called pre-exposure prophylaxis or PrEP, should also reduce the rate of new infections further.

But all of these measures together will not cut HIV transmission to a sufficiently low level for the epidemic to be effectively eradicated. I know, mathematical modelling has shown that *if* around 80% of sexually active people opt for testing once a year, the epidemic could be more or less eradicated by 2050.

However, that’s a very big if. This sort of modelling has no bearing on the practicalities of how the sort of decrepit health and social service levels found in high prevalence countries will ever persuade large numbers of people to test regularly. At present, testing is between 10 and 20% of populations and that's after many years of trying to persuade people to test.

Epidemics are inherently unpredictable and we have been, consequently, fairly poor at predicting which direction the HIV epidemic will take. In the US, which hasn't lacked funding, high levels of circumcision and concentration on abstinence only education has resulted in the highest HIV prevalence in the developed world.

HIV spread rapidly in developing countries, especially among people in densely concentrated populations with low levels of education, health and social services and very high levels of gender and economic inequality. But well educated and wealthy people were, at least at one time, more at risk than poor and less well educated people.

Now, HIV is spreading in less densely populated areas and the effects of having such low levels of education, health and social services are clearly felt in that most HIV prevention efforts are failing. They are failing because, unsurprisingly, they require good education, health and social services; what a surprise!

Yes, people who are infected with HIV need to be treated, and they need a lot more than just drugs. They should be entitled to this treatment and care and that should also cut transmission considerably. But for widespread treatment to effectively cut transmission, we also need to target the people who are presently being infected with HIV and those who are at risk of being infected.

The process of identifying all infected people is too big a job to effect quickly enough to protect people who are presently uninfected. Targeting those who are presently uninfected means providing everyone with adequate health, education and social services. This means *not* spending all available money on drugs, mass male circumcision, PrEP, trying to test every sexually active person, etc, and providing people with the basics that they need just to survive.

I agree with those who are calling for more money for HIV but no amount of money will make up for the fact that people lack the most basic things. The current approach to HIV appears to assume that HIV is independent of the overall environments in which people live. HIV is not independent of each aspect of people’s day to day lives; no disease is. On the contrary, HIV is transmitted rapidly where people work and travel and behave much as they have been doing for as long as anyone can remember.

HIV transmission is reckoned to be low at the moment in Zimbabwe (although prevalence is high) because people’s day to day lives have been disrupted. The same thing is said to have happened in other countries that experienced wars and civil disturbances, such as Ethiopia and Angola. But that doesn’t mean that rates of HIV transmission will stay low in those countries.

Like all diseases, HIV is part of everyday life; it affects people who are rendered vulnerable by decades of falling public spending. A bigger chunk of the money needs to be spent on healthy people. I know that doesn’t fit in with the plans of the pharmaceutical companies and others who make a lot of money out of disease but healthy people need the means to stay healthy. If all the money is spent on drugs, healthy people will continue to suffer, as they are doing right now.

(For further discussion of PrEP, see my other blog,


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