Tuesday, May 11, 2010

Good News for UNAIDS: We Know How to Turn Off the Tap

An article in the New York Times suggests that the "war on global Aids" is falling apart. Although drug prices have fallen dramatically and the number of people on antiretroviral drugs has risen, this effort to give HIV drugs to everyone that needs them has proved to be unsustainable. In countries like Kenya and Uganda, most of the funding was provided by donors who are now reducing funding, partly, they say, because of the global financial crisis.

But the article suggests that the financial crisis is not the only reason. Big donors are disillusioned at their lack of success, despite spending huge amounts of money on the problem. "For every 100 people put on treatment, 250 are newly infected"; prevention programmes have either been too expensive or almost completely ineffective or both. Donors are now going to turn their attention to cheaper diseases.

Using an often used metaphor, Dr David Kihumuro Apuuli, DG of the Uganda Aids Commission says that "You cannot mop the floor when the tap is still running on it". The executive director of the Global Fund to Fight Aids, TB and Malaria is "frustrated", a researcher from the National Institute of Health is "pessimistic", Obama's Aids Ambassador is "worried", the executive director of UNAIDS is "scared" and the former executive director "has seen optimism soar and then fade".

Well, David, Michel K, Anthony, Eric, Michel S, and Peter, there is a way to reduce the flow from the tap, even if we don't know how to turn it off completely. This may eventually reduce the flow to a trickle and the number of new HIV cases every year could become so small that there is no longer an epidemic. Yes, a new direction is required, but this new direction has already been researched carefully and described by a number of experienced researchers.

Here's what we need to do: we need to re-evaluate the considerable evidence that unsafe medical practices are contributing a lot more to HIV transmission than is currently estimated by UNAIDS. We also need to include in this re-evaluation unsafe cosmetic practices, especially those that, either accidentally or on purpose, draw blood and thereby contaminate instruments.

Aids spending has concentrated overwhelmingly on treatment for much of the last three decades. And much of the money spent on preventing new infections went on mother to child transmission and some rather hopeless exhortations to abstain from sex, reduce numbers of partners and use condoms. Safe sex and increasing condom use are very important for reducing sexually transmitted HIV but they are completely useless when it comes to non-sexually transmitted HIV.

To continue the rather tired metaphor, UNAIDS and many other concerned parties have been turning the tap the wrong way, because anyone infected non-sexually can go on to infect others through sexual contact. Those who are now disillusioned because the number of people becoming newly infected every year still exceeds the number receiving treatment may be inspired when they see this trend slowing down. They may be persuaded to continue paying for more treatment if they think that the numbers of new infections will go down every year from now on.

It has been obvious for a long time that the small number of countries in the world where the vast majority of HIV positive people live are not inhabited by people who have unbelievable numbers of sexual experiences with incalculable numbers of sexual partners. Indeed, only a very dedicated adherent to some long discredited and rather racist views of African people could even countenance such an explanation.

So, HIV prevention is not so intractable as some would have us believe. Yes, it's hard to influence sexual behaviour to any great extent. But if less HIV transmission can be put down to sexual transmission then a lot of money currently being spent on the programmes that are not working can be saved for something worthwhile. And money spent on health services now will result in immediate savings. Ensuring safer medical and cosmetic practices will prevent both direct infections and the indirect infections caused by those infected directly, either sexually or non-sexually.

I call on UNAIDS and all those working in the field to take the official advice, to 'Know your epidemic (or pandemic), know your response'. To understand why HIV has been spreading the way it has in high prevalence countries, we need to look at the most efficient ways of spreading the disease: blood contact. A combination of unsafe medical practices and unsafe cosmetic practices is continuing to spread HIV simply because the official view is that HIV is predominantly spread by unsafe heterosexual sex in high prevalence countries and that blood exposures are so rare as to be insignificant. You know your response has failed, therefore, how well do you know your epidemic?


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