Wishful Thinking And Wilful Lobbying

Further to my last posting, which was about universal HIV testing and treatment (UTT), I would like to point out that the advocates of this strategy make it clear that UTT would be combined with currently used prevention approaches. The authors are not suggesting that all the current approaches can be discontinued. They are idealistic but they do have one foot in the real world.

Some of those who have jumped on the UTT bandwaggon, on the other hand, seem to think that current approaches will cease to have much relevance. Similar remarks apply to another technical solution that was fashionable for a while and still is in some circles: mass circumcision. It was feared, even when mass circumcision was first mooted as a strategy for HIV prevention, that people would experience 'disinhibition', that they would think being circumcised meant they didn't have to bother with other precautions.

But that's the problem with bandwaggons, every new toy is seen as the future until it is replaced by the next toy. Using every strategy possible to prevent transmission of HIV is rarely discussed. In fact, strategies that don't relate fairly directly to sexual behaviour are rarely discussed even though they are numerous and would have benefits beyond HIV prevention.

Perhaps there is a feeling of unease developing among some of the loudest proponents of UTT. Maybe they are beginning to feel that many of the prevention strategies that have been employed so far have been a complete failure. Perhaps they wish to bury most of the failed strategies that emanated from dogmatic, right wing moralising rather than from any evidence, scientific, social or otherwise.

But UTT makes very good commercial sense for the makers of pharmaceutical products that are so expensive that most people can’t afford them. Given that the majority of people with HIV live in the developing world, pharmaceutical companies wouldn’t have much of a market for their products unless they could persuade governments and international institutions to pay for them with aid money. And they seem to have been very successful in this endeavour.

Much HIV policy thus far has depended on the assumption that a sexually transmitted infection can be prevented by targeting sexual behaviour and by aiming to regulate the forms sexual behaviour should take. But firstly, it was never reasonable to assume that these could be achieved. Secondly, these policies failed to take into account the determinants of people's behaviour, sexual and otherwise. These policy makers were not really interested in the effect their policies were having, they were just interested in seeming to say the right thing in front of their electorate and/or their funders.

Very early on in the HIV epidemic, HIV was handled by doctors and other technical and medical personnel and this was a period of rapid learning and adaptation. Doctors and others were quick to warn about what steps should be taken to contain what could become a serious epidemic. On the whole, they did a good job, especially considering they were working in the dark.

But HIV quickly became a football for politicians, religious leaders, journalists, pundits of all kinds and, of course, NGOs. There was little that medical practitioners could do anyway and the field was soon full of people jostling for attention. HIV attracted enormous amounts of money and at the same time deflected money, attention and personnel from other issues. These processes continue today.

Prejudices were fed by the same political and religious leaders, journalists and anyone else who felt they should have a say. We saw, and still see, moral outrage, blame (on women, sex workers, immigrants, gay men, Africans, whoever), finger wagging, posturing and anything but effective prevention strategies or the money to pay for them.

Now that this potential technical solution has come along, are we going to see a quiet retreat from these long held dogmas? And if so, will the issues of cross generational marriage, female genital mutilation, the low status of women, labour rights denied, lack of health, education and other services no longer be considered important?

The rush to embrace UTT sounds like a tacit admission that prevention strategies up to now have been a failure and that it is not possible to legislate for people's sexual behaviour. These are both true, of course, but this doesn't mean that UTT will work, whether on its own or in conjunction with existing strategies. If UTT is to work, many other conditions need to be fulfilled first.

HIV has been decontextualised and ahistoricized. Every epidemic has a history and a context. The epidemic in Kenya is different from those in Uganda and Tanzania. In fact, the epidemic in Nairobi is different from that in Mombasa. There are few sex tourists in Nairobi, for a start. But the commercial sex work that takes place in the central business district is quite different from the problems faced by the 70% of Nairobians who live in slums. The epidemic around the Mumias Sugar Company is different from the ones in the towns bordering Uganda. The problems of tea plantation workers in Kericho differ from those of the nomadic people of Northern Kenya, and so on. The determinants of HIV transmission are many and various, requiring many and various solutions.

UTT is yet another solution that is blind to such distinctions as epidemics that are driven by economic need, lifestyle, labour conditions, abuse and exploitation, poverty and whatever else. UTT assumes that HIV is primarily a medical problem and, as such, that it is the same in every country in the world.

UTT could work well in countries with good health, education and social services, buoyant countries with low levels of inequality and good legal and governance structures that protect people's rights. Kenya is not such a country, neither are any developing countries. That's why they are called developing countries.

Universal HIV Testing and Treatment, the Latest Fashion

The philosopher Ludwig Wittgenstein spent much of his early years as a philosopher solving all the major problems of Western philosophy. So he thought, anyhow. He spent his later years trying to answer some of the questions that his earlier philosophy raised. Since his death, philosophers have moved from trying to understand Wittgenstein’s work to trying to dismiss it or trying to explain it (or explain it away). But there are still philosophical problems, and there probably always will be. I certainly hope so.

Similar claims have been made about the end of science, as if all the major scientific problems have just about been answered or soon will be. There’s also the end of history, whatever that could mean. And then there was the long held assertion that capitalism was the only way for global economics to proceed. That was until all the major capitalist economies answered the question as to what would come next: an absurd form of communism, it seems. And after that, who knows?

Well, maybe it’s just journalists and writers of a journalistic bent who still feel the need to raise such possibilities as the end of various intractable problems, for example, of development. Thus, a recent article in the New Scientist entitled “Are we about to eliminate AIDS?” This article was motivated by a much publicised article suggesting that if universal testing were carried out in all countries with endemic HIV and all those found positive were to be put on antiretroviral treatment (ART), HIV transmission would plummet and prevalence could be maintained at a very low level by 2050.

I have discussed this latter article on several occasions and I’m sure I’ll return to it, but for now, I’d like to have a look at the claims made in the New Scientist article. Right at the beginning the article claims that it would only take existing medical technology to eliminate AIDS. This highlights a major flaw in current thinking on HIV: that it is a medical problem and will, eventually, have a medical solution.

There are medical ‘solutions’ to many of today’s health problems. The biggest killer of children in developing countries is pneumonia and other lung infections. There are solutions to many economic problems. There needn’t be hunger or malnutrition in developing countries because there is plenty of food. Quite a number of medical problems don’t require medicine, they need clean water and good food. Why is a technical fix so often seen as the only way out of a problem?

The history of HIV in Kenya is just a small part of a history of processes of ‘negative development’ carried out by the Kenyan government, various business interests, foreign governments, international financial institutions and other parties. These processes are still being carried out. Members of the government are still trying to amass wealth and power as are the business interests. Foreign governments are keen on wealth as well but power is especially important to them. It’s hard to work out what international financial institutions are interested in. Their habit of screwing up the economies of developing countries is inexplicable unless they are doing it to benefit some of the wealthier countries, but I’ll have to leave that for someone else to explain.

So bringing in a technical fix, universal testing and treatment (UTT), will not reverse the effects of what has been happening in the country since independence. The technical fix will be very successful if health, education, food security, the environment, infrastructure and all other underdeveloped sectors of Kenya are also improved. But those are very big ifs. UTT will have a chance of working if Kenya is allowed to develop.

The cost of UTT is vast. The article promoting the idea is a mathematical model and it points out that the cost of not rolling out UTT is even greater, if a long term view is taken. If the cost is vast, I would suggest that those enamoured with the idea should check on conditions in Kenya that would need to be met in order to achieve universal testing alone, when in the last 15 years they haven’t even achieved 25% testing. And UTT requires testing every sexually every adult frequently, perhaps every year.

As for the millions of people who will be on ART, what about the support services they will require? Perhaps around 35% of the people who are known to require ART are receiving it. These figures are vague, but the health services are struggling to get the numbers up as it is. And all that’s needed is a crisis like the one that occurred after the elections last year and many people are back to square one.

But crises don’t come singly in Kenya. The post election crisis was followed by water, fuel, food and financial crises. Each of them affects the ability of the country to care for its sick, not just those with HIV. The country is underdeveloped, many development indicators are going in the wrong direction. This is why Kenya has endemic HIV in the first place and it is why efforts to reduce transmission have failed so far.

UTT will not fail because the idea is a bad one, it will fail because it is a solution that requires many years of development work to occur first. And if that development work is carried out, the cost of UTT will come down, too. The cost of UTT is nothing to the cost of allowing Kenya to develop in ways that have been blocked for so many decades.

But to return to the article in question, the New Scientist one, the author claims that people on ART almost never transmit HIV, even during unprotected sex. That is a very contentious claim, many would consider it a rash one to make. But if there is any truth in it, it is only true of those responding to ART who have a low enough viral load. In Kenya there are those who don’t have access to the drugs, for whatever reason, those without access to adequate nutrition, those suffering from other serious medical conditions and those who don’t take the drugs in the recommended manner, etc. They probably can still transmit HIV or will be able to soon enough.

And what is this about HIV being the only or the biggest risk from unprotected sex? Condoms can also be used to protect against unwanted pregnancy, or hasn’t the author heard of that? There are also other sexually transmitted infections, do they not count? Herpes simplex virus (HSV) is sexually transmitted, incurable and endemic in Kenya. It also increases transmission of HIV.

I applaud the people who have worked to find a cure for HIV and those who have come up with treatments. I also applaud those who put the mathematical model together showing the promise that UTT holds. I just wish they would look a bit wider than their own profession, whether they are doctors, epidemiologists, virologists or whatever. There is the whole of health, health services, development and many other things to consider if such ambitious projects are to work.

I’m glad the issue is being discussed by huge numbers of people but HIV is not just a medical or scientific problem and medicine and science do not operate in isolation from histories, cultures, societies, economies and especially, from people, their lives their ways of behaving, their circumstances and many other constraints.