HIV Drug Resistance is a Consequence of Irresponsible Drug Use

The availability of antiretroviral drugs (ARV) for HIV treatment, especially in high prevalence countries, has been welcomed by many, and rightly so. Only an estimated one third of people who need treatment are currently receiving it in Kenya and accurate figures about how many people are being successfully treated are probably not available. But the situation is a lot better that it was in the early 2000s, when drugs were still unaffordable (to donors, they will probably always be unaffordable to most Africans) and only a few thousand people were able to access them.

There have long been warnings about careful management of ARV rollouts. One of the main worries was about resistant strains of HIV developing in large numbers of people where the treatment program was not being administrated well. Because, while the cost of ARVs is high, the cost of second line ARVs, needed when resistance develops to first line drugs, can be five to ten times higher. But eventually, a lot of resistance will develop because people are not responding to treatment it or are not taking it according to requirements.

Even in countries with relatively well established treatment programs, drugs of all description are in short supply. Uganda is now depending on emergency funding just to supply existing patients with ARV drugs, let alone dealing with new patients or ones who are affected by resistance. Taking the drugs in accordance with requirements can be impossible for many people.

However, a related worry is that of transmitted resistance. Those who are not on ARVs can acquire a strain of HIV which is already resistant to first line drugs. A study in Zambia has found that almost 6% of HIV positive people who are in need of treatment are resistant to first line drugs. It's all very well to say the people involved can be treated with second line drugs. But in addition to the massive increase in costs involved, second line drugs are just not as widely available.

The trouble with resistance, whether acquired or developed, is that it will eventually reach high levels. In countries where ARV programs have long been available, resistance can be as high as 20%. Coupled with this, recent WHO guidelines recommend starting ARV treatment at an even earlier stage in disease progression (though some question the wisdom of this). That sounds great but, not only are numbers of people on treatment in African countries very high, health services and health infrastructures are weak, very weak.

Similar circumstances have already given rise to resistant, multi-drug resistant and extensively drug resistant TB. The problem doesn't get resolved by the production of stronger drugs unless the circumstances that gave rise to resistance are also resolved. Many people in Kenya who are HIV positive also have TB. But many who don't have HIV do have TB. 50% of people with TB are not HIV positive. These are two separate epidemics, despite considerable overlaps. Resistance in either TB or HIV treatment will fuel at least one, perhaps two devastating epidemics.

Monitoring and testing for poor adherence to treatment and resistance are expensive. African countries are struggling to implement the most basic treatment services, let alone such advanced facilities. Some of the costs may go down, but unless broad health systems are developed, the lack of adequate facilities, trained personnel and equipment will mean that the majority of people are still vulnerable.

You can't expect weak health services to implement massive, high technology programs. Yet, this is what seems to be expected of African health services. The majority of people have little or no access to primary health care, water and sanitation, adequate food and levels of nutrition, some of the most basic aspects of health. People die of diarrheal conditions and respiratory problems. What chances have they with HIV and TB?

The HIV agenda has been driven by the desire of pharmaceutical companies to sell drugs at the highest price they can get to the largest number of people possible. Not only is resistance, acquired and developed, a consequence of allowing Big Pharma to drive the HIV agenda. Resistance is also an excellent way of increasing their profits further. But what about the epidemics? What about people who are HIV positive and those who are in danger of becoming infected?

If donors, governments and the HIV industry can accept that preventing and treating HIV is not just a matter of distributing ever increasing quantities of drugs, the agenda should include other items, such as the need for more and improved hospitals, more and better trained and motivated personnel, better equipment and supplies. People must be able to access primary health care, not a bunch of kiosks that give out drugs, almost willy-nilly. And good health also requires good infrastructure, education, food security and a whole lot of other things.

It's the job of Big Pharma to sell drugs but it's not the job of UNAIDS, the WHO, national governments, academic institutions and other parties to support them and their excesses. Prevention of further transmission of HIV is getting lost in the process of selling drugs. Some even believe that prevention of HIV transmission will be effected by greater consumption of drugs. This is not the case. Countries that are devastated by epidemics are not just markets; epidemic and endemic diseases will not be eradicated by treating them as commercial opportunities. Use of drugs for HIV treatment must be responsible, which it is not at present.

(For a discussions about pre-exposure prophylaxis (PrEP) and resistance, see my other blog.)

Measurement of Success is the Measure of Our Failure

Out of the top ten killer diseases listed by AlertNet, most relate to a lack of something very basic:

Number one, lower respiratory infections are closely related to poor environmental and living conditions; 2, HIV/AIDS is related to many things, including healthcare, education, infrastructure, labor practices, legal issues, equality and others; 3, malaria is to a large extent related to environment and living conditions; 4, diarrhea is mostly related to poor water and sanitation; 5, TB, environment and living conditions.

It's not until you get to numbers 6 to 9, measles, whooping cough, tetanus and meningitis that you find diseases that are generally controlled with a vaccine. And controlling these diseases still requires adequate health systems, education and infrastructure. Number 10, syphilis, can also be controlled by good sexual healthcare, sex education and drugs.

But the point is that medical treatment is not health. Medical treatment is for people who are sick. In order to avoid numbers one to five, the majority of people need things like good housing and domestic facilities, water and sanitation, access to nutritious food, education and the protection of the law against discrimination, exploitation and inequality. If these basic needs are not met, medical treatment alone is unlikely to be of any use. These top ten killers kill millions of people because of the absence of things other than medical treatment and supplying endless amounts of medicine will not prevent illness and death.

The AlertNet article is perverse in that it doesn't mention that the biggest killer, lower respiratory infections, are spread by poor living conditions and that, therefore, deaths could be significantly reduced by concentrating on improving these conditions. One of the Millennium Development Goals includes reduction in child mortality as an indicator of progress. But that doesn't necessarily translate into improving living conditions. Children are especially susceptible to respiratory infections and much of the mortality from these causes occurs in children and infants. But providing lots of treatment is not a substitute for better conditions.

Similar remarks apply to malaria. It can be better controlled if people live in decent housing. When they live in villages, towns and cities, especially, the environment also needs to be such that malaria carrying mosquitoes can be controlled. But a large percentage of people live in semi-permanent housing that doesn't protect them from mosquitoes and other threats. Mosquito nets are good if people have enough space and enough beds to make them effective, yet many live in cramped conditions where mosquito nets are less effective. Technical solutions need the right conditions and have sometimes proven to be a waste of money.

One often hears calls for vaccines against diarrheal diseases and big donors are especially fond of such vaccines.  But what these big funders don't seem to want to ask is why are people drinking water contaminated with their own feces? These vaccines may have some impact at first, but if people don't have access to clean water and good sanitation, they will continue to be infected with other water borne diseases. Is it even logical to give some medicine to people who then continue to drink contaminated water? Vaccines may be a good supplement to eradicating some of the big killer diseases but without ensuring safe water and sanitation, they will have little effect. The same applies to pneumonia vaccines.

Providing people with decent living conditions, water and sanitation and the like are expensive. But billions of dollars are spent on vaccines, much of the money going to rich and powerful multinationals. There isn't a lack of money, just a lack of equity. Most of the money is being spent on subsidizing the rich; pharmaceutical giants, agriculture and the like. It's true that most people in developing countries don't die for lack of food, and malnutrition doesn't usually kill people either. But these both leave people weaker, more susceptible to disease and more likely to die of preventable and treatable diseases.

Sometimes it appears that development misses the point: yes, people are poor, undereducated, unhealthy, isolated and otherwise deprived. But a handful of indicators is not a measurement of development. The aim of development is not to produce a few Olympic runners, jumpers and throwers and then claim some gold medals. The aim is that everyone can enjoy healthy and fulfilled lives. Achieving some goal such as immunizing all (or most, or 80%) of children against a couple of waterborne diseases is a failure if they still die from some other waterborne disease; it's a failure if they don't have access to clean water and good sanitation. Immunization, like much medication, can be a necessary condition to ensure health, but it is not sufficient.

Of course, development experts are not advocating that everyone be supplied with medication and ignoring other conditions. But the money is mainly going towards the technical solutions and not going towards supplying basic needs. In developing countries, many people spend more money on healthcare and health care products than they do on more basic things. And where they don't have the money to spend, a lot of development money is spent on these services and products. Basic needs are prior, in the sense that they must be supplied first. In highlighting how basic some of the top ten killer diseases are, AlertNet takes the first step towards refocusing attention. But it fails to say why so many people in developing countries are dying needlessly or what can be done about it.

Fiddling with Technical Fixes While People Continue to Die

Time reports on a study which raises concerns about HIV drug resistance. Most Kenya government documentation about HIV treatment is concerned with getting as many people on treatment as possible, or appearing to do so. Where the aim is to get as many drugs out to as many people as possible, resistance is probably not so visible. After all, you need to monitor people regularly and carefully for signs of resistance and funding doesn't always stretch to that.

It's not really clear how many people in Kenya are currently on HIV treatment. Figures vary a lot and don't always make it clear whether people who were once on treatment but have since died are included. Probably a few hundred thousand are on treatment at the moment, maybe three hundred thousand. But it's even less clear how many are on second line treatment. Second line treatment is given to those who have developed resistance to first line treatment and it's prohibitively expensive.

Most of the hundreds of millions of dollars of HIV money is spent on drugs, either for treatment or prevention. No one would want to deny people who are suffering from HIV/Aids access to necessary drugs, of course, but there must be a limit to how much money can be spent on drugs to the almost total exclusion of other aspects of treatment and prevention. I don't know what that limit is but there are proposals to put even more people on drugs and the sustainability of these proposals is highly questionable.

At present, people whose HIV infection has reached a particular stage are usually put on antiretroviral drugs (ARV). Perhaps about half the HIV positive Kenyans who have reached this stage are currently receiving treatment. Pregnant women who are infected with HIV are put on a short course of ARVs and this results in most babies growing up HIV negative. Less frequently, people who may have been accidentally infected with HIV can be given a short course of ARV treatment called post exposure prophylaxis (PEP).

But there are proposals to roll out ARV drugs to more and more people. For example, it was proposed just over a year ago to test everyone, or as many people as possible, and to put anyone found to be HIV positive on ARVs. If this could be done, the number of people on treatment would go up several hundred percent.

Another proposal is to roll out what is called pre-exposure prophylaxis (PrEP). This would involve putting HIV negative people on ARVs in the hope that this would protect them from becoming infected. The target of this kind of programme would be those seen to be most at risk of contracting HIV. This could involve sex workers, men who have sex with men, prisoners, intravenous drug users and perhaps the clients of sex workers, people who have many parters and people who have concurrent sexual partners, relationships that overlap with other relationships.

The number of people who would be targeted would be hard to estimate. How many men who have sex with men are there in Kenya? Is it five percent of the population or 10 percent (2-4 million)? Men who have sex with men are hardly going to identify themselves in the current homophobic climate anyway. An obvious target of PrEP is people who are HIV negative but are in a relationship of some kind with someone who is HIV positive, called discordant relationships. This could number some 350000 people.

Similarly for sex workers, how many are there? Is it hundreds of thousands and does that include people who occasionally engage in sex work or who don't consider themselves to be sex workers? And what about identifying their clients, how many million would there be? Is it really feasible to identify those most at risk of becoming infected with HIV? The recently published modes of transmission survey shows that, for years, HIV programming has been seriously misdirected and also that those who are most at risk is a very mixed and constantly changing group.

There are questions about the possible effectiveness of PrEP but there must also be questions about the feasibility of identifying all the people who could benefit from it, given the numbers of people who are infected with HIV and the numbers of people who are in danger of becoming infected. If resistance is a problem at current levels of ARV rollout, what kind of problem would it be if ARVs were rolled out to all people at risk or thought to be at risk of contracting or of transmitting HIV?

All the uses of ARV run the risk of resistance. Those who are HIV positive and on ARVs are at risk, but so are the women who receive short courses of ARVs to prevent mother to child transmission, so are those who receive post exposure prophylaxis, so are those who receive pre exposure prophylaxis. With resistance comes increased sickness and death unless second line treatment is rolled out. And second line treatment means increases in cost of several hundred percent. Again, questions about sustainability arise.

The question of whether we can treat our way out of the HIV epidemic is constantly raised but the answer is unclear. I would suggest that the answer is no and that even efforts at preventing the spread of HIV should steer clear as much as possible from technical fixes, such as ARV drugs. Drug treatment of HIV, let alone drug prevention, may not be sustainable and is already seriously affecting the amount of money available for preventing HIV transmission.

Instead of the almost inconceivable amounts of money being proposed to pay for drugs for treatment and prevention, far lower sums of money could be spent on improving the overall health, education and welfare of Kenyans and of those in other high HIV prevalence countries. It is immoral to continue pretending that there is a technical fix just around the corner and that everything will be OK. As long as we continue to look for technical fixes and ignore the lives of people in underdeveloped countries, people will continue to become sick and to die from treatable and/or preventable conditions.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Will PEPFAR Become a Fund for Health?

It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.

The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.

The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.

So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.

But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.

Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)

Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.

The One Trick Pony That Can't Defy Gravity

When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:

The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".

Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).

I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.

But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.

I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.

I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.

Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.

But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.

Foundations for HIV Prevention

I rarely come across articles criticizing HIV prevention programmes for their lack of success, but apparently a contributor to the Social Aspects of HIV/AIDS Research Alliance conference this year draws attention to the fact that many 'prevention' interventions were implemented without ever being tried. He may have gone on to say that ones that were tried and found to be useless continue to attract most prevention funding, but I wasn't at the conference.

Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.

It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.

But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.

Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.

Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.

HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.

Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.

The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.

The Aids Industry Sure Knows How to Blow its Own Trumpet

Yesterday was World Aids Day again and in Kenya you couldn't miss the copious amounts of advertising, bunting, leafleting, t-shirts, sun visors and other paraphernalia of the industry. High and not so high officials were out in strength to collect their per diem, without which, presumably, nothing important could happen. There were the mobile testing clinics in areas that already have static testing clinics and millions and millions of condoms distributed.

For all it's faults, the Aids industry has published some figures that certainly look good. Botswana, which has one of the worst HIV epidemics in the world, has the highest percentage in any African country of people on antiretroviral therapy (ART), the highest rates of HIV testing and the highest number of women on ART to prevent mother to child transmission (PMTCT). They also have the third highest percentage of children on ART.

Over several decades, the campaigns to recognise the rights of HIV positive people to receive treatment have been successful in a lot of countries. In many developing countries, a sizable percentage of HIV positive people in need of treatment are on treatment. In the West, very few babies born to HIV positive mothers are themselves HIV positive. Indeed, the percentage of HIV positive babies born to HIV positive mothers is declining in a number of developing countries too and should be relatively low by now in a country like Botswana, where such a high percentage of HIV positive mothers are receiving PMTCT.

But rights seem to be most commonly recognised for those who are already infected with HIV. If you read various developing country HIV strategic plans (which are curiously similar, despite the epidemics being very different in quality), you will notice that the word 'rights' is rarely used except in relation to HIV positive people, mainly in relation to access to treatment. The rights of those who are not yet HIV positive, and that's most people, are rarely mentioned. Yet they have a right to the things that will ensure that they remain HIV negative.

Of course, it is hard to quantify the effects of the various HIV prevention programmes that have been rolled out in Kenya and other African countryies. Most of them were run by wealthy organisations who could afford the 'research' and publicity that would make them look very successful. The reality is that very little is known about preventing HIV and, beneath the hype, few programmes have been truly successful.

I would be the first one to admit that the very idea of cutting HIV transmission is fraught with difficulties. Many things have been tried, some of them perhaps even well thought out. But in the end, there is very little money to be made out of prevention and therefore very little money put into it. Condom distribution is an exception, but where there is little or no health or science education, let alone sexual and reproductive health education, condoms haven't really taken off that well. You may have heard otherwise but there are good commercial reasons for that.

The problem with the majority of the prevention programmes that have received some of the relatively small amount of money that is available for HIV prevention is abstinence. Most programmes relied on the idea that if people would just abstain from sex, they would not be likely to be infected. The more liberal advocated abstinence until marriage, until it was noticed that more and more people are becoming infected by their spouse. But various programmes were cobbled together that, one way or another, advocated abstinence or what amounts to abstinence. People didn't abstain and most of them won't. This is not something peculiar about developing countries. Abstinence campaigns have failed where ever they have been tried.

The reason I mention the rights of people who are HIV negative is that many of them will, sooner or later, become infected with HIV because one or several of their rights are presently being denied. People, whether adults, children, male or female, have a right to health and a right to treatment when they are sick. Yet more people in Kenya and other developing countries are dying of easily treatable and curable diseases than are dying of Aids.

Children have a right to a decent education and part of that should include levels of health and science education that should give them the prerequisites to attain enough understanding of sex, sexuality and reproductive health to avoid becoming infected with HIV or other sexually transmitted diseases and to avoid unplanned pregnancies. In a word, people need education to lead healthy lives.

People have a right to a decent standard of living for themselves and their children, they have a right to adequate food and nutrition, they have a right to good standards of governance and security, water, sanitation, infrastructure and many other things. They have a right to a legal system that protects them from harm and persecution and the like. Women need to be given the same rights as men, in the workplace, in the economy, in education, in health and everywhere else. Men who have sex with men, intravenous drug users and commercial sex workers need their rights protected.

It is the denial of the sorts of rights mentioned above, along with various other rights, that leaves people vulnerable to becoming infected with HIV and suffering many other serious consequences. People in developing countries who are suffering from HIV now, and those who have died of it, were likely denied one or several of their rights. HIV is not transmitted in isolation from people's circumstances, from the conditions in which they live and work.

Those who are HIV positive and those who are HIV negative are equally entitled to their rights, though skewed funding for Aids would suggest that this is not the case. In order to avoid transmitting HIV to others and in order to remain HIV negative, everybody's rights need to be protected. In short, everyone is entitled to these rights and without them, the treatment and care programmes for people who are HIV positive will be, to a large extent, in vain; the half hearted prevention efforts will also be in vain.

Prevention has proved to be a slippery fish. But treatment and care for one disease in isolation from all the other things people can and do suffer from has also been less successful than it should have been. There is little point in treating one incurable disease and ignoring the many others that are more easily treatable and often even curable. But that is what's happening. The Aids industry is just too rich and powerful to allow people to know that.

HIV Treatment is Necessary, But Not Sufficient, For Prevention

Medicins Sans Frontieres (MSF) has published a report on reduced funding for HIV treatment, from the World Bank's Global Fund and the US Government's President's Emergency Fund for Aids Relief (PEPFAR) in particular. MSF have good reason to be worried.

The pharmaceutical industry successfully lobbied governments and international institutions to pay huge amounts of money for antiretroviral (ARV) drugs that most of the people suffering from HIV/Aids would never be able to afford. In fact, the governments of countries with high rates of HIV/Aids would never be able to afford these drugs, either.

Countries like Kenya have the option to produce generic versions of ARV drugs at a fraction of the price that is currently being paid. But most countries, including Kenya, have chosen not to exercise this right, preferring to enact laws that make it unlikely that the country can produce or even purchase such cheap generic versions. Good relations with the pharmaceutical industry seems to be more important to them than saving the lives of their citizens.

MSF are right, huge ARV rollouts cannot now be stopped without endangering the lives of millions of people who are HIV positive and even people who are, as yet, HIV negative. But rather than arguing for the money to keep coming, in fast increasing amounts, they could concentrate on finding ways of reducing the cost of treatment so that it can continue and even expand.

How much of the billions of dollars of aid money have been spent on building factories to produce drugs that people need in Kenya? I haven't heard of any. Most of the money has been spent in ways that don't go on to produce anything or increase the country's sustainability or self reliance. The funds have mostly been spent as if HIV is just an emergency.

Well, it is something of an emergency, but there are underlying factors that are not part of an emergency. The country has a decaying health service, decaying education sector and a small and decaying infrastructure. People are poor, unhealthy, badly educated and unable to access vital services, such as clean water and proper sanitation. These are the things that face the majority of Kenyans every day, whether they are HIV positive or not.

Money spent on drugs, regardless of the overall condition of health systems is, to a large extent, wasted. Many drugs go out of date before being distributed, they get to people unprepared to take them properly, they are taken by people who are dying of other, easily prevented and treated illnesses, etc. My argument is not that ARVs should not be purchased and distributed and prescribed; it is that there needs to be a proper, accessible health service for all this to happen.

There is not a proper health infrastructure in Kenya, there hasn't been for a long time and increased HIV/Aids funding has not brought about a health infrastructure that serves people's needs. True, there are many clinics and institutions that were not here before HIV/Aids and wouldn't have even appeared. But these mostly deal with HIV/Aids, not other, basic health problems that people face.

My argument is also directed at the emphasis on HIV/Aids treatment over prevention. MSF's Goemaere is right to object to the prevention/treatment 'dichotomy'. Of course treatment has a positive effect on prevention efforts. But it is not enough to try to treat our way out of the epidemic. This is clearly not working and much more needs to be done to prevent new infections. Otherwise, the aim to treat everyone who requires treatment becomes even less attainable and less sustainable that it is right now.

People who are HIV positive need more than just drugs, or even treatment. There are a lot of threats to their health and welfare than HIV. They are dying because they are too far from the hospital, because the hospital is not up to the job of caring for them, because they are entitled to benefits they don't know about or that have been stolen by someone else, because they are poor and isolated and not considered important enough. But there just aren't the services needed to support chronically sick people and these will not just appear because the country is swamped by HIV/Aids (treatment) related institutions and programmes.

Those who are HIV negative need to stay that way and this won't happen by rolling out ARVs, alone. They have needs that are far more important and urgent that the possibility that they may become infected by something that won't kill them for many years. Most won't live for very long anyway, for a huge variety of reasons that are not being addressed right now.

Goemaere recognises the false dichotomy of treatment/prevention, but fails to see that increasing treatment while effectively ignoring prevention will not combat HIV/Aids in the long run. Assuming that HIV treatment will also prevent infections is not enough because it doesn't prevent enough infections and it never will. And treatment will never be as efficient as it should be if health, education, infrastructure and other social services continue to be ignored.

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, pre-exposureprophylaxis.blogspot.com)