Applying the paradox of prevention: Eradicate HIV
From Griffith REVIEW Edition 17: Staying Alive
© Copyright Griffith University & the author.
Written by Bill Bowtell
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Imagine it: some fifty thousand young Australians suddenly struck down and killed by a new virus. One hundred and forty thousand more infected and kept alive only with complex, expensive and painful therapies. The outlook is grim. The caseload increases exponentially, hospitals are at breaking point, the economy has stalled, and a generation has been decimated. The authorities and the public are confused, depressed and overwhelmed.
And then, miraculously, an antidote is developed. Almost immediately, most are cured. The health budget is relieved of the immense costs of providing indefinite treatment to one hundred and forty thousand infected people. Even more impressively, the providential cure raises forty-three thousand young people from the dead. They resume their truncated lives, pay taxes, raise families and otherwise enrich themselves and the society that had been deprived of their talents.
Regrettably, another seven thousand cannot be resurrected. But better to lose seven thousand than seven times that number, to manage twenty thousand infections not seven times as many. Relieved of a generational catastrophe, the health system and the nation cope resiliently with a small, manageable problem, not a large disaster. Sustained use of the miracle cure keeps the problem contained and controlled for the indefinite future.
This is not a sentimental script for a B-grade movie, but a scenario that is more or less true – only the sequence of events is reversed. The virus is HIV – the Human Immunodeficiency Virus. By September 2006, 23,065 Australians had been infected with HIV. Since the virus was first reported in Australia in October 1982, 6,658 people have died from Acquired Immunodeficiency Deficiency Syndrome (AIDS) caused by HIV.
But another one hundred and twenty thousand Australians were not infected with HIV. Fifty thousand people did not succumb to AIDS. No miracle antidote cured them, or raised them from the dead. Instead, in the very early years of the epidemic, Australia developed a response to the potential threat of HIV that kept tens of thousands of young people alive and free of infection. The response was not an antidote, but a vaccine. Not a vaccine of the body, but of the mind. In Australia, the vaccine that brought HIV under control was behavioural prevention. The spread of the virus was contained because people made simple changes to risky behaviours, persuaded to do so by the timely mass distribution of honest and useful information about the nature of the virus and how its transmission from person to person could be prevented.
The Australian response worked astonishingly well. In 1983, Australia, North America and Western Europe had roughly comparable rates of HIV infections and AIDS cases. From the mid-1980s on, however, Australia pursued policies that were radically different from those adopted in the United States which opted for harsh, punitive policies that often demonised the virus as a divine punishment for sin. The American government refused to implement needle and syringe exchanges to provide uninfected equipment to injecting drug users, or to sanction national sexual education campaigns and condom distribution. Notoriously, President Ronald Reagan only once uttered the word "AIDS" during his entire eight-year presidency from 1981, when American cases of HIV grew from almost none to nearly a million.
After two decades of applying radically different policies, the American and Australian outcomes are, hardly surprisingly, radically different. Twenty five years on, Australia's rate of HIV prevalence is 75 per hundred thousand, compared with 402 per hundred thousand in the United States. Australia's incidence of AIDS per hundred thousand is 1.3 compared with 14.3 per hundred thousand in the United States. There can be little doubt that, had we adopted American approaches, we would now have similar outcomes – perhaps a hundred and twenty thousand additional cases of HIV over this time, and another fifty thousand cases of AIDS.
It is, of course, impossible to know exactly how many Australian HIV and AIDS cases were averted because of our rational and pragmatic policies. But it is clear that embracing large-scale behavioural prevention paid immense human and social dividends. Many thousands of young Australians have grown to adulthood free of HIV infection and without risk of dying from AIDS; and health and social services were spared the costs of providing additional therapies and welfare payments to those affected by the disease. Funds and resources not allocated to HIV/AIDS were directed to other health care challenges and needs.
This year marks two important anniversaries in the Australian response to HIV/AIDS. It is the twenty-fifth anniversary of the first Australian case of HIV infection reported by Professor Ron Penny in Sydney in October 1982. It is also the twentieth anniversary of the comprehensive Australian government HIV/AIDS package, introduced in April 1987, which responded to all aspects of the emergency – care, treatment, research and prevention. The most memorable feature of the package was the "Grim Reaper" television commercial, which brought home to the entire population the menace and nature of the problem and paved the way for sustained long-term behavioural change.
As we look back over a generation, we can see how radical, inspired and effective this response was. For little more than $100 million a year (in 2007 dollars) outlaid over twenty years to cover all HIV-related care, treatment, prevention and research, the domestic threat of HIV/AIDS was contained. Australia produced by far the best outcome of any comparable country. Only New Zealand, with a much smaller population, did better. In this country, however, success is an orphan while defeat has a thousand fathers. With a laconic shrug of the shoulders, our success in containing HIV/AIDS is taken for granted. The great achievement has fallen victim to the paradox of prevention – if it is done well, its success is not apparent.
SO WHY, AFTER ALL THIS TIME, should we worry about HIV/AIDS? If the rest of the world had managed it as well, there would be very little reason for concern. While the problem in Australia improved, the situation elsewhere deteriorated alarmingly. The truth is that, in the two decades since Australia acted to control AIDS, what was once a minor health emergency has morphed into a global pandemic with immense social, economic, political and epidemiological ramifications. Twenty-five years on, sixty-five million people have been infected with the virus, and more than twenty million have died from AIDS. The pandemic is poised to recreate the same havoc of suffering in the Asia Pacific region – in our immediate neighbourhood – that it has already caused in Southern Africa and Central Asia.
I have been involved in Australian HIV/AIDS policy since just after the first case was notified. I was part of the group of politicians, bureaucrats, advisers, doctors, nurses, nuns, sex workers, gay men, drug users, academics, journalists, advertising executives and social workers responsible for the Australian response. When in 1987 we implemented what turned out to be the right policies to contain HIV, I naively assumed that, in Churchill's phrase, we had at least reached the end of the beginning. As our policies worked, and new Australian HIV cases fell rapidly in the 1990s, I expected that other countries and international agencies would learn from our achievements and those of the handful of other countries that deployed effective prevention policies. It seemed inevitable that the global response would be constructed around the principles of effective behavioural prevention. After all, this was a simple and cost-effective inoculation that had worked before, that was far better for individuals and health budgets, and altogether far less socially, politically and economically disruptive than letting a pandemic run its course.
My fond expectations were dashed. During the 1990s, the lessons of behavioural prevention were, in practice, ignored. They were not adopted on a global scale; they were not the subject of celebration or replication. In a way, the failure to bring HIV/AIDS under control in the 1990s is more astounding than the ease with which a handful of countries – including Australia – suppressed the problem at its inception a decade before.
We are now a quarter of a century into the unmitigated catastrophe of a global pandemic. The outlook for its further evolution is grim. The strategies followed by international agencies to contain it are manifestly not working well enough to cap and contain the spread of the disease. There is no commitment to effective global prevention programs, even though the principles and methods that would prevent large-scale transmission have been tried and tested. Instead, vast resources are being directed to care and treatment of a caseload that is expanding so fast that there is almost no hope of providing enough drugs even to those who most urgently require them. The sheer number of cases has brought in its wake new, highly contagious strains of tuberculosis, and may lead to increased resistance to any form of treatment. Health systems in small, fragile states are being stretched beyond breaking point.
This has gone on long enough. The half-baked alternative strategies that were meant to contain and control HIV/AIDS have instead indirectly contributed to its spread. A generation has been sacrificed to strategies that owe more to misguided piety and blind faith than science and evidence, victims of an approach that discounts the basic realities of human nature and behaviour.
For twenty-five years, weak politicians and timid bureaucrats cravenly opted to build a response based more on resolving and avoiding political conflict and controversy than facing up to the stark realities of the threat. Many political leaders responded by seeking to build a consensus between religion and science where none was possible or desirable. Some scientists and institutions who knew better acquiesced in crude policies that they were warned could never succeed. They became meek enablers and apologists for misguided strategies and policies that have directly contributed to the present mess.
When Australia, along with a small group of other countries, picked the problem for what it was, the response was right. But in much of the world for a generation, these pragmatic lessons of prevention were recklessly ignored. Twenty-five years and almost twenty-five million deaths later, it is time to judge what has worked and what has failed, to call to account those responsible for the present situation and, for the first time, to organise and fund the entire global HIV/AIDS strategy entirely on sound scientific principles.