Friday, July 16, 2010

HIV Industry Parties As Virus Spreads

The HIV industry has a very important junket coming up in Vienna and some of the industry's biggest donors are threatening to reduce funds. The World Bank's Global Fund and the US PEPFAR fund (President's Emergency Fund for Aids Relief), which represent a large proportion of global HIV funding, will be reduced over the next few years. Industry representatives are busy writing press releases, lobbying governments and doing everything in their power to fight for their right to party.

That sounds very cynical, but many people will die of Aids during the coming Vienna Aids Conference and during the many expensive junkets the industry treats itself to. The amount of money spent on such events must be astronomical and they are not usually even held in countries with high HIV prevalence. The same amount of money spent on HIV prevention or treatment could save a lot of lives. But HIV policy is mainly written by Westerners in expensive Western offices and when the policy is written, the writers celebrate in Western bars.

With all the hype around the much touted 'Treatment 2.0', it's hard to believe there will be much left to talk about at the conference. Ironically, there is a lot of talk about the use of mobile phones, laptops, wireless and various other technologies in the fields of HIV and global health in general. But you wouldn't think it to see all these people rushing to some expensive city, first class, expenses paid. Treatment 2.0 does involve a lot of technology, but not the sort that reduces costs or carbon emissions or anything like that.

According to PlusNews, one of the five priorities at the conference is 'universal' access to HIV drugs. This, despite what you might expect, involves putting 80% of people who need drugs on ART (antiretroviral therapy). The target was to achieve this by the end of 2010 but this will not be met by most countries. Even the target of putting everyone with a CD4 count (a measure of immune strength) of 200, rather than the WHO recommended 350, will not be reached.

Another technological approach is called 'treatment as prevention', the idea that people who are responding to HIV treatment will be less infectious and so will not be likely to transmit HIV. In ideal conditions, this works well. However, with so many countries still a long way from their targets, it is unlikely to have much impact in high HIV prevalence countries. In most of these countries, a substantial percentage of HIV positive people don't even know their status, so they will not be on ART. Treatment as prevention has been talked up for nearly two years now but no one has dared to admit that it is an ideal and will always remain an ideal. Even the jokers who came up with the 'no sex month' idea don't believe it.

Even nuttier than that is an approach called pre-exposure prophylaxis (PrEP). This involves putting those 'most at risk' of being infected with HIV on ART. If we had any idea who was most at risk we could have prevented a lot of infections by now. But we have been pretty unsuccessful in predicting who was most at risk in the past. And recent Modes of Transmission Surveys have shown that many of the people who are becoming infected are not in at risk groups. In fact, one of the characteristics of high HIV prevalence countries is that many of the people most likely to become infected are at low risk, according to official definitions! Figure that one out.

So there are a lot of technologies available but they are either not being used or they are not proving too effective in the field. It is difficult enough to persuade people to get tested for HIV once, let alone once a year for the rest of the time they are sexually active. Many who are HIV positive are either not taking the drugs, not taking the drugs properly or do not have access to the drugs or some other aspect of treatment (shocking, but no, you can't just hand out pills). Perhaps a lot of people are on treatment, but many of them will, eventually, develop resistance and need to go on to a far more expensive 'second line' drug. Technology is not simple, but conditions in developing countries are basic.

So what are the problems, if all this money has been spent for so long? Well countries need infrastructure, especially health infrastructures. They need education, especially health education. They need adequate levels of nutrition and food security. They need clean water and sanitation and many other goods that are considered to be human rights. You cannot roll out a high tech treatment or prevention program without countries having some level of development. It may seem possible to the HIV industry, donors or the public. But not only is it not possible, we've spent years demonstrating the impossibility.

In addition to these technical problems and the problems relating to our relative lack of understanding about exactly how HIV spreads, there is another problem, which is harder to characterize. This is the problem of the HIV industry's refusal to accept that we cannot explain high prevalence, generalized epidemics (where the majority of those infected are not members of high risk groups, such as intravenous drug users, men who have sex with men or sex workers) by almost exclusive reference to heterosexual sex. If you refuse to accept the racist, sexist explanations of HIV transmission in African countries being due to the fact that Africans have lots of unsafe sex, you will also refuse to accept that HIV prevention programs that target sexual behaviour, and nothing else, will reduce transmission to the extent that HIV will eventually be eradicated. I don't see what there is to celebrate.

(For further discussion of PrEP, see my other blog,


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