Wednesday, July 28, 2010

HIV Treatment As Prevention; the Hole in the Patch

Various factions in the HIV industry, and indeed some in the global health industry, are like a bunch of inept tinkers trying to patch up a colander in the hope that they can use it as a pot. They all rush to one hole and stick their latest ill-gotten patch on it, and then stand back to see how well it works. Invariably it doesn't work, but they churn out some more patches and stick them on other holes that they belatedly start to notice. Sooner or later there are patches on top of patches and, alas, still too many holes for boiling cabbage.

What the industry has always tended to miss is that when they try to stick on a patch, for example, by telling everyone about how HIV is transmitted and how they can avoid being infected, they find that there is no infrastructure for this to be effected. There are too few schools, too many students, too few teachers who know too little and too many barriers for some people to go to school or for others to gain much by doing so. A large proportion of the population does not have access to the mass media, which may or may not have the freedom to do what the HIV industry would like them to do.

Once testing was possible, this too was 'rolled out'. And over 20 years or so, about 20-25% of people in developing countries found out whether they were infected or not. It was established that HIV was transmitted sexually and that condoms gave good protection against infection. So condoms were distributed and people were encouraged to use them. Estimates of condom usage vary but it has been difficult to get condoms to the right place in time and to encourage consistent use. But health facilities, both primary health care facilities and others, such as pharmacies and sexually transmitted infection clinics were underfunded, understaffed and oversubscribed. To many, they were completely inaccessible.

So it was expected that educating people about HIV and providing them with what meager facilities were available would be a good place to start. But many people didn't go to school and schools were not very good. And many people didn't go to hospitals and they weren't very good either. The majority of HIV 'prevention' strategies were stymied not because they were rubbish (though many were), but because there were certain prerequisites that hadn't been met. Obvious though some of these prerequisites were, health, education, infrastructure, social services and the rest, they are still wanting.

HIV is not the only disease that has attracted this kind of 'vertical' approach, nor the only disease that the global health industry has failed to have much impact on. There is a whole set of water-borne diseases, some of which have been approached individually, some not. Most of these efforts have failed, not because the diseases can't be prevented and/or cured but because people who suffer from them are still drinking contaminated water. Clean water and adequate sanitation would enable people to avoid some of the most debilitating and deadly diseases.

Respiratory infections kill millions of people, especially infants and under fives. But the environmental and other conditions that result in these infections killing so many have not been dealt with. Many infants die because they don't receive even the most basic level of care; young children die of measles and meningitis; mothers die because of inadequate maternal care; and people of all ages die of malaria, TB and other treatable and curable diseases.

Ensuring health is not about curing diseases, it is about providing people with the conditions that will allow them to avoid these diseases. But the tinkers in the industry think they can run around after sick people and thereby keep others healthy. 'Treatment is prevention', the idea that putting all HIV positive people on antiretroviral drugs so that they are less likely to transmit the virus to others, will fail. It will not fail because the drugs don't work, they do. But most people have not been tested; others refuse to take the drugs; others don't have access to the drugs; and others still take the drugs but they don't work. And while this is going on, far too many people are still being infected with HIV.

Developing countries do not have the infrastructure to test every single sexually active person, let alone test them every year. They don't have the capacity to supply every HIV positive person with drugs, to monitor them, treat them and support them adequately. You can introduce 'task shifting' (a proposed alternative to providing enough trained professionals), microbicides that may work a little, circumcision that probably won't work very well and any other patches the tinkers can dream up. But those basic things that people need most correspond to their human rights.

Allowing people their human rights may not result in HIV being eradicated quickly, given that it has been spreading so long and has infected so many. But the only hope for reducing transmission to the extent that the virus can be eradicated completely is for all those infected to receive treatment and care and for all those who are HIV negative to be provided with everything they need to ensure their complete health. And providing treatment and care and preventing the further spread of HIV requires good health services, schools, infrastructure and public services. Overall health doesn't result from targeting a handful of diseases. Rather, overall health and well-being in a population means that most diseases can be targeted, treated and controlled.


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