Monday, April 9, 2012

HIV Policy: Can Science Be Apolitical?

Several times I have been taken to task for, among other things, using the term 'HIV industry', as if there is some homogeneous group of people beetling away in the field of HIV who all think pretty much the same way. But my use of the term is a way of expressing the view that many people benefit from HIV as if it is, to them, a kind of commodity. Interestingly, a paper called 'Limits to evidence based health policymaking: Policy hurdles to structural HIV prevention in Tanzania' (link to full article), by Moritz Hunsmann, cites some people who make money out of HIV and also use the term 'AIDS industry'. (I chose 'HIV' rather than 'AIDS' because where prevention is successful, even where treatment and care of HIV positive people are successful, AIDS is less common; otherwise my blog would be called 'AIDS in Kenya'.)

Because of a massive inflow of international funding, "HIV is big business", "thousands of people make a living from HIV/AIDS in Tanzania", "many people in Tanzania would prefer HIV being there for a while!", according to various respondents. There is a demand for money to do things that the big NGOs are experienced in doing, such as abstinence workshops, rather than, say, reducing co-factor diseases in HIV transmission, like malaria, schistosomiasis and TB. What HIV money is actually spent on is not a matter of evidence, it's a matter of interest. Worse, the policies are heavily influenced by those same interested parties.

In contrast to the lowly role of evidence in the choice of priorities, quick political returns are vitally important. Broader 'structural interventions', which may address the "legal, political and socio-economic contexts in which people make behavioural decisions", are not only too long term, but outcomes that don't relate fairly directly to HIV are considered to be 'externalities'. Behavioral interventions are considered to deliver quick returns, even though many would admit that they have delivered very little; it is the sheer amount of money that has been spent on them that is presented as the measure of their brilliance.

Ironically, if an intervention were to eradicate schistosomiasis, malaria and other diseases which have been shown to be significant co-factors in HIV transmission, the very fact that these diseases affect hundreds of millions of people would make it look like the money had been wasted. That hundreds of millions of lives would be improved and millions more saved would be 'externalities'. For far smaller amounts of money, a lot more could be achieved by addressing co-factors, and HIV transmission would also be reduced at the same time. But the 'vertical' approach to HIV (and other diseases) means that a parallel health system has been cobbled together which, while failing to reduce HIV very much in the last 10 years, has had little or no impact whatsoever on other diseases.

The amounts of money involved in Tanzania' HIV epidemic are mind-blowing: "97 percent of HIV-related expenses are donor-financed and external support for AIDS control represents over ten percent of public expenditure and one third of all international aid", "available resources for HIV/AIDS increased fifteen-fold between 1994 and 2007, reaching USD 520 million annually - roughly the equivalent of the country’s health budget for all non-HIV concerns combined", etc. Much of the money over the last 10 years comes from the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for HIV (TB and malaria).

A common excuse given for not changing the way HIV is currently addressed, as mainly a matter of individual sexual behavior, is that "We don’t want to complicate our messages"; the excuses go on: “[P]eople would feel safe and may not protect themselves anymore” if they thought it wasn't purely a matter of sexual behavior. Yet these are also reasons for not implementing mass male circumcision programs or pre-exposure prophylaxis (PrEP). But as the author says: "Changing a whole continent’s sexual behaviour ... is generally considered a feasible endeavour." A whole continent's assumed sexual behavior, that is. High levels of unsafe sexual behavior were attributed to high HIV prevalence countries because heterosexual HIV transmission is not efficient. But attributed levels needn't be so high if the biological co-factors Hunsmann and others are drawing attention to are added to the equation.

Interventions that go beyond sexual transmission of HIV, including structural interventions, are not more costly or less cost efficient, as some would claim. Nor are they in any way less relevant to HIV. There is no lack of evidence for their effectiveness, unlike the behavior change interventions on which so much has already been spent, the effectiveness of which was unknown before the were implemented and is all too well known now. Rather than risking underselling Hunsmann by paraphrasing his conclusion: "Excluding the political nature of prevention policymaking from the analysis exposes AIDS players and scholars to repeated frustration and hampers the formulation of scientifically sound and politically informed strategies for positive change."

Much though I appreciate Hunsmann's approach and his careful analysis, I wonder if he is being polite towards scientists or if I am misunderstanding him. Many scientists also appear to be part of the HIV industry and to use or not use evidence, depending on the circumstances. I wouldn't suggest that policy makers are too scientific, far from it, but I suspect many scientists of being highly political, perhaps far more political than rational at times. Surely many of them are also involved in policy-making? Surely many of them have control of substantial budgets? Perhaps the struggle between science and politics is sometimes within, rather than between, various players.


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