Sunday, November 20, 2011
After flailing around blindly, spending billions and ending up with little to show for it, the massively wealthy but spectacularly ineffective AIDS industry may finally box its way out of a wet paper bag. What it will do after that is another matter. But it's nice to see progress, however hard it is to detect.
Right at the end of a paper entitled 'Redesigning the AIDS response for long-term impact', Heidi J Larson, Stefano Bertozzi and Peter Piot make a few things clear which have, up until now, been clear to everyone but those working for the AIDS industry. But they do now accept that funding should support infection control programs relating to safe blood transfusions and injections.
Unfortunately, they deprioritize infection control in general. This would be fine if infection control was covered by health system strengthening funding (or some other way), but it's not. It would also be acceptable that AIDS money no be longer used for sexually transmitted infection (STI) programs if STI reduction received funding from elsewhere, but it doesn't.
The authors note that "The difficulty of changing sexual and drug-using behaviours was...greatly underestimated" and that "prevention tools continue to be implemented without evaluating their effectiveness in different settings." But they don't appear to question the entire vertical approach to HIV/AIDS at a time when health funding in general was totally inadequate in high HIV prevalence countries; the approach to HIV has only diverted funding further.
Instead, they seem to be suggesting that HIV funding be focused even more narrowly than before, rather than on just avoiding ineffective approaches. Do they not yet see the bigger picture of HIV epidemics thriving in countries with low and flat or declining health spending? Instead of talking about mainstreaming, integration and other nice theories, how about treating HIV as just another disease, with overlapping determinants to other diseases, such as hepatitis B and C, with similar needs, such as functional and safe health services?
Reducing HIV transmission is not just a matter of scale, as these authors must appreciate, being aware of the huge increases in funding for lucrative areas of HIV treatment and the like. But the industry, if it's to have any impact on transmission, needs to lose its obsession with sex and African sexuality, and look at disease transmission in context. This means tracing the risks HIV positive people have faced, not just tracing the sexual risks they face; non-sexual risks also need to be reduced, which involves informing people about them and how to avoid them.
Let's leave the fatuous reflexes about 'treatment being prevention' for the marketing people because treatment is not prevention. More than two and a half million infections a year show that treatment is not prevention. Saying we need to put more money into treatment will not make treatment into prevention either. Most new infections occur among people who only face low levels of sexual risk (though the industry has failed to assess non-sexual risk).
But even if treatment could possibly become a significant part of prevention, and there are serious doubts, who will be paying for this? Current programs are failing because of falling funding and an almost complete absence of infrastructure, in other words, a complete lack of health systems strengthening, among other things.
The authors conclude that there are "no short term solutions". At the rate they are going, that's all too true. But the "fundamental redesign" they call for requires a closer look at a disease that is difficult to transmit sexually, yet it spreads quickly among people whose sexual behavior is similar to that of people everywhere. The question is still 'why Africa, why Africans'? The industry needs to answer that question.
[For more about non-sexual transmission of HIV through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]