Tuesday, May 25, 2010

Big HIV Funding and Blatant Racism

Many people and organizations in the HIV world, especially those involved in HIV treatment, as opposed to prevention, are worried about the effects of global financial belt tightening on HIV budgets. They are right to worry. A lot of big funders are capping funding or reducing it. And the global financial situation may not be the only reason for this austerity.

For many years, HIV prevention has taken a back seat to HIV treatment. Those in favour of treating as many people as possible and ignoring the fact that more people are becoming infected than going on treatment, assure us that mass roll out of treatment also plays a part in 'health systems strengthening'. This is supposed to make those concerned about a high rate of new infections feel better, as if new infections are being taken care of because those infected for some time are being treated in great numbers.

Indeed, defenders of the status quo that involves treating those who are infected and almost completely ignoring new infections, explicitly argue that HIV treatment also prevents new infections. To an extent that is difficult to quantify, this is true. HIV positive people who are responding to treatment (which means they also need adequate levels of nutrition and general health, etc) tend to have a lower viral load. They are less infectious and, therefore, less likely to infect others.

But this still leaves others vulnerable to infection. If many were not currently vulnerable to infection, the rate of new infections would be negatively correlated with the number of people who are responding to treatment. Those in favour of treatment at the expense of prevention claim to be averting infections, but only by using a circular argument; that the number of new infections must be lower than it would have been if treatment hadn't been rolled out because treatment reduces the incidence of new infections. The fact is, widespread treatment hasn't yet reduced new infections very much.

Well, if these treatment fundamentalists are really concerned about the effect that cuts in funding will have on the lives and health of people in developing countries, there are a number of alternatives they could consider. For a start, they will have to make some effort to reduce new infections at some stage. No person or organization would be wise to keep spending money on outrageously expensive drugs for treatment when the numbers of infections continues to rise, more or less unabated.

So these concerned and worried parties (Michel Kazatchkine, Michel Sidibe and others) can start campaigning for the sole use of generic versions of antireteroviral drugs (ARV), at least in poor countries. At present, expensive, branded versions are used almost universally. There has been a lot of pleading about how much pharmaceutical companies have dropped their prices but these reductions are nothing compared to the savings that use of generics could bring. To argue for more or continued funding for overpriced medicine is stupid and downright deceitful.

With the money saved by switching to generics, some money could be spent on prevention. And I don't mean the ABC (abstain, be faithful, use a condom) rubbish that has been churned out for more than ten years. This 'behaviour change communication' and any prevention programmes based on the idea that Africans have lots more sex than anyone else, has never worked and it never will work. More money has probably gone into publicity to show how successful this disgraceful waste of money has been than into programmes that really do work.

Plenty of research has shown that most of the 'prevention' programmes that have been carried out so far have achieved little, especially as far as reducing HIV transmission is concerned. But there is also research that receives a lot less attention which shows that HIV transmission can be reduced significantly, but also cheaply. Larry Sawers and Eileen Stillwaggon have argued for this in several publications, including in an article entitled 'Understanding the Southern African 'Anomaly'; Poverty, Endemic Disease and HIV'.

In this article, Sawers and Stillwaggon demonstrate that HIV transmission can be influenced by inexpensive measures such as providing people with deworming, sanitation, STI (sexually transmitted infection) treatment, mosquito control and safe water. These, they argue, are all essential in controlling HIV. In addition, these measures all have benefits that go beyond their effects on HIV and will improve the lives and health of tens of millions, perhaps hundreds of millions, of people in developing countries.

There is a lot of good money to be made in the HIV industry, especially where expensive drugs are involved. Attention to these drugs has been far higher than the success of ARV rollout could explain. Yes, many people are alive now who would not be alive without the drugs. But this has been achieved at a cost that is far higher than necessary. And as a result, preventing new infections has been given short shrift, even though this can be effected at relatively low cost. One might almost think that HIV has been seen as an opportunity to sell vast amounts of drugs that have a very small market outside of developing countries.

To make it clear, in case people may think I'm advocating against spending money on drugs for people who are HIV positive: I believe everyone who is in need of HIV drugs should receive them, but I believe they should be purchased at the lowest cost possible. This is not currently the case. Costs are kept artificially high by intellectual property laws (In other words, market protectionism) that favour rich countries and multinationals, by behind the scenes deals, by lobbying and by fancy marketing and publicity. The big HIV funders are being robbed blind, or perhaps they are being robbed and happen to be blind as well. I also believe that HIV positive people should have all their other health needs attended to and that they should have access to an adequate diet without which the drugs and treatment they receive are useless.

Once the cost of treating HIV positive people has been set at a level that poor countries and poor people can afford, there should be a lot more money available for preventing new infections. The approaches mentioned by Sawers and Stillwaggon, above, are all vital. And they are compatible with others, such as identifying instances of HIV being transmitted non-sexually, whether by unsafe medical practices, cosmetic practices, unsafe traditional medical practices or whatever.

As long as the big earners in the HIV industry continue to spend billions on overpriced medicine when cheaper alternatives are available, their wailing about rights and justice are so much hypocrisy. They are long enough in the business now to know what is going on, a lot better than laypeople do. And it must be as clear to them as it is to anyone who bothers to check that HIV prevention has to accompany HIV treatment if the disease is to be eradicated. Equally, these big earners cannot continue to ignore the evidence that they are wrong about sexual behaviour in African countries. Levels of risky sexual behaviour are higher in America and Europe than they are in Africa (and Sawers and Stillwaggon are particularly clear on this point in all their publications). Claiming otherwise is blatant racism.


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