Applying the paradox of prevention: Eradicate HIV - Page 7
From Griffith REVIEW Edition 17: Staying Alive
© Copyright Griffith University & the author.
Written by Bill Bowtell
IN THE EARLIEST YEARS OF THE PANDEMIC, those countries that successfully contained it did so because they distinguished between the need to prevent transmission and the need to care and treat those with the infection and illnesses. This is properly located within the health system, buttressed by specialist research and development into new and improved therapies.
HIV prevention is not about care and treatment, but the provision of information and the necessary technologies to enable the consumers of information to translate intention into action. Care and treatment happens "after the event" while prevention is, axiomatically, about stopping the event. The skills and knowledge required to implement effective prevention campaigns are found in the creative arts – advertising, marketing and the media. As a profession, doctors and clinical researchers have none of the skills, experience or training to qualify them to devise, implement and expand prevention campaigns.
By definition, HIV prevention must be directed not where the problem is, but where it is not – at younger, sexually active people and those most likely to experiment with injecting drugs (also most likely to be young). They are unlikely to visit clinics and hospitals, but they can be reached in schools, malls, workplaces, sporting and entertainment venues, and through television, radio, films, phones and the internet. Young people at greatest risk of infection won't be found in churches, synagogues, mosques and temples, but in places where they can have sex and even do drugs. Many young people hang out in cyberspace. To work, HIV prevention messages must be delivered to young people where they are, in ways that make sense to them. Above all, prevention campaigns work best when they are stripped of moral judgments, and overt editorialising about virtue and social improvement.
In many countries, HIV prevention programs are being applied that are based on these precepts and strategies. International agencies and donors have increasingly funded such campaigns. There have been some notable recent success stories in, for example, Cambodia, as a result of mass prevention campaigns and promotion of condoms to young people, there are encouraging signs that HIV rates are falling. In 2005 Taiwan responded to rapidly increasing rates of HIV infection among injecting drug users by introducing a needle exchange and methadone substitution program. Infections that had risen rapidly from negligible levels in 2003 jumped to 2,500 new cases two years later, but after the new programs were introduced fell to about 1,700 the following year.
International agencies have funded and supported a range of effective prevention measures based on the undeniable evidence that such programs work. But, as the present rate of new infections demonstrates, the core problem is that – although effective – these prevention measures are not being implemented fast enough, widely enough, well enough or in enough jurisdictions to make a truly significant difference.
One of the lamentable consequences of the great cultural and religious brawl over AIDS was the merging of the response into one consolidated strategic structure. The creation of UNAIDS in 1996 was the purest expression of the idea that all elements of the crisis could be dealt with by one supra-agency, with one governing council, one set of administrators and one set of model rules that, with some variations, might be applied universally to contain the pandemic. At the time, this idea seemed to make sense. However, the effect has been to advantage the interests of care and treatment over the requirements of large-scale prevention programs. The creation of UNAIDS coincided with the development of the first wave of truly effective and useful anti-retroviral therapies. Soon the interests of those involved in care and treatment predominated. The great increases in funding were delivered primarily to increase care, treatment and research.
Virtually the entire upper echelon of the UNAIDS' management structure and its plethora of specialist advisory committees are dominated by medical practitioners and clinical researchers. For completely understandable reasons, the most enduring and dynamic links within and around these organisations became those between the agencies, the pharmaceutical companies at the forefront of new drug development, the universities and research institutions and clinicians driving HIV clinical research, the governments most desperately seeking new treatments and the vast range of nongovernment organisations, charities, churches and agencies representing the interests of those infected with HIV or suffering from AIDS illnesses. The political force and power of the bloc of interests that assembled behind care and treatment is immense – power which was wielded to drive up the level of support for care and treatment, especially in Africa. As the caseload rose, care and treatment became a common objective around which all sides of the debate could coalesce.
There is no constituency for HIV prevention that can remotely rival that advocating care, treatment and research. The care and treatment coalition determines priorities; convene conferences and influence politicians, donors and the public debate about the allocation of scarce resources. Everyone with HIV and AIDS has, by definition, an urgent need for support. They will always have the first call on funding because they can demonstrate need. In crude terms, there is now a global constituency of forty million people directly affected by the virus, and another hundred million or so living with indirect economic and social burdens of the disease. In politics, numbers count. Politicians and bureaucrats ignore numbers and need at their peril. Responding to the multifaceted and urgent need for care and treatment is more pressing than the spending time and money on prevention. By its nature, those advocating prevention find very few seats the top table, although the constituency of those at risk of HIV infection is far larger than those who require treatment. The social and economic benefits of these young people not contracting HIV are obvious but the political benefits are negligible. The urgent has trumped the important and generated a peculiar but real moral hazard.
This orthodoxy suits the interests of the care and treatment coalition. It assumes that donors will be content to provide ever-increasing funds to subsidise the production of new treatments, that primary health care systems in poor and fragile countries can cope with the burden of distributing new therapies to large numbers of patients, that there are few problems with developing resistance and immunity as new treatments are used, and that a large and growing HIV caseload will not also encourage the emergence of new more virulent co-infections, notably new strains of tuberculosis. The unanswered question that must be asked of those who believe in the interests of care and treatment over prevention is the simple one: "Who pays?"
THE DEVELOPMENT OF EFFECTIVE THERAPIES has been a great benefit. It is only right that these therapies should be made available to all who require them. But this is simply not going to happen. Only about 10 per cent of the ten million cases in most urgent need of HIV therapies receive treatment. In many parts of the world, primary health care systems are deteriorating rather than improving. To improve these systems will require, in some cases, social reconstruction and reform that is impossible without political upheaval and economic dislocation of a scale that would only encourage rapid spread of disease and illnesses of all kinds, including HIV.
The vision of a world treating a large, expanding HIV caseload through universal distribution of highly subsidised treatments is an illusion that borders on the deranged. This vision is based on assumptions that are uneconomic; socially utopian and that may have dramatically adverse collateral public health consequences. Only the dramatic, early reduction of new cases can bring about long-term stabilisation. If this happens, there is at least some prospect that available resources can be applied to meeting the goal of universal access to treatment and testing within the framework of existing public health structures. This in turn will reduce economic, social and public health risks that are now being ignored or downplayed in the rush to support care and treatment.
The conventional wisdom is that prevention is not possible because the social and cultural barriers are impossibly high. But the costs of persevering with the present strategies concerned only with symptoms, not causes, are mounting by the month. There are parallels with climate change. At some point the costs of patching up a failing model become too high to sustain. It is time for the international response to be reformulated around a simple and clear universal goal – the eradication of HIV/AIDS.
The goal of international public health policy should be the elimination of the disease within three generations. After twenty-five years of trial and error and impressive strides in clinical research, we can at last discern how all the disparate elements of the global response might now be brought to bear on the problem to achieve the goal of eradication.
Continuing scientific research into the nature of the virus might conceivably result in a cure or a vaccine (in the commonly used sense of that word), but the nature of the virus is such that neither a cure nor a vaccine seems likely to be developed quickly. It is more promising that a range of therapies will be developed that make transmission far less likely by reducing the HIV viral load in infected people. If viral load is reduced below a certain level, transmission will be impossible. It seems likely that new forms of biomedical prevention may also greatly reduce the risk of transmission. For example, vaginal spermicides could provide women with a means of preventing the risk of infection. There is increasing evidence that male circumcision reduces transmission and therapies that somehow replicate the barrier effects of male circumcision, without requiring removal of the foreskin, might be developed.
Medical science will continue to generate therapies useful in care and treatment that hold out the promise of a silver bullet cure. But, by their nature, medical science and research deal with the symptoms not the cause. If a cure is discovered, that will be a great boon – but we cannot base global HIV/AIDS policy on the probability of such a welcome eventuality.
If HIV eradication is the goal, to achieve it we must fund and support behavioural prevention at levels that can make a real difference. The target market for behavioural prevention is all young sexually active people and those who may be exposed to the risk of infection. Existing strategies assume that prevention education should be directed at groups at highest risk. This was a useful template to target scarce resources to areas where the greatest benefit could be obtained and worked best in Western countries, where broad definitions of high-risk groups were grounded in similar social realities. But even in these countries, HIV rates fell fastest and furthest when there were general campaigns aimed at the entire population as well.
The world is a highly diverse and culturally dissimilar place. The template of prevention education developed in the mid-1980s did not work well when applied to developing nations. But this does not mean that campaigns designed specifically for people in developing countries cannot be successful.
IT IS CLEAR THAT EFFECTIVE HIV PREVENTION education must be directed at the entire population and especially young people who are most likely to be sexually active and to experiment with drugs. Regardless of cultural differences, most people are disinclined to make profound changes in behaviours they enjoy or that are important to them. They accept that the world is full of risk that can never be eliminated. This is especially so when it comes to sexual activity. No strategy whose success depends on the denial of sex can possibly succeed over time within a large population.
The only strategy that can work to reduce HIV transmission through sexual contact is one based on promoting minimal behavioural changes consistent with eliminating HIV infection while accepting that people will continue to have sex as they wish. This is also the rationale for tackling the smaller numbers of people who are inclined to use illicit drugs out of choice or compulsion. In terms of HIV/AIDS, those jurisdictions with the highest rates of infection are generally those with the harshest penalties for illicit drug use. In recent years, the link between harm reduction and reduced rates of new HIV infection has become very apparent. A more rational approach to controlling demand for illicit drugs will inevitably lead to reducing new HIV caseload among injecting drug users.
HIV can be eliminated if the twin forces of applied medical research and effective behavioural prevention measures, informed by detailed social research, are applied in tandem. Eradication is entirely possible, provided we employ all the tools and knowledge we possess. Effective measures must deal both with the problem of HIV and AIDS where it is and where it is not – that is, among young, uninfected people. New treatments are becoming available that should keep people with HIV alive and reduce their viral loads. This means that the great benefit to individuals of living longer and better lives will be spoilt by the risk of a longer living HIV positive person passing on infection to others. Certainly, some forms of prevention education are best undertaken in conjunction with HIV testing and treatments. Greater availability of tests and treatments can help overcome stigma and discrimination as can greater levels of knowledge about HIV and how its transmission can be impeded. All of these measures and more are required to cap and contain the growth of new cases. The simple technologies of prevention – condoms and clean needles – must be made available to all those who seek them, without discrimination or sanction. In time, new forms of biomedical prevention will become available and these too must be widely distributed and promoted.
Those who object to HIV prevention on religious or moral grounds have very little evidence to support their position, Over the last twenty-five years, it is clear that restricting the distribution of useful information and preventive technologies has not deterred people from indulging in risky behaviours. Programs that accept the realities of human sexual behaviours work far better than those that deny them. Many are unwilling to challenge orthodoxy and disturb the status quo. But there is no good reason why the emergence of a new threat should not be assessed and dealt with by all societies. In time, cultural norms and practices are revised as people take account of changing circumstances.
The objections of the care and treatment coalition to behavioural prevention are substantial and deserve serious consideration. It may well be that the billions of dollars so far invested in clinical research will deliver useful treatments and may in time produce forms injectable vaccines. A "eureka" moment is always possible. But in the coming decade those responsible for care and treatment will have their hands more than full coping with the global caseload. They should stick to what they know best, and leave others to get on with the job of upgrading the global prevention effort.
After a generation of missed opportunities, policy failures, administrative incompetence and confusion, and above all shockingly bad outcomes, we must turn finally to simple behavioural prevention and place it at the heart and not the periphery of the global response. Existing structures, strategies and funding models must be overhauled to give priority to prevention. Approaches that have failed should be stripped of their funding by the global programs that continue to support them. Benchmarks and goals must be established and investment measured against performance. Clear lines of political accountability must be established for those paid to administer the global effort that manages the pandemic.
For all their faults, the present international structures are doing as well as possible in increasing funding and support for care and treatment. But much more needs to be done to bring about universal provision of prevention services. It may be that the cumbersome and unwieldy structures of the UN simply cannot be relied upon to provide effective global prevention programs. Instead, it may be that new private sector structures and initiatives – perhaps supported by the Gates Foundation – would bring the drive, purpose and imagination to prevention that is so obviously lacking in the present response.
The single greatest failure of the global response to HIV/AIDS has been the absence of a coherent, integrated economic case for prevention. The world dealt with the emerging pandemic bound by the shackles of painfully outmoded public health models and assumptions. Australia contained the epidemic by abandoning those elements of the public health model that made no political, social or economic sense. The decision to entrust the global response to the archaic public health model embodied in the World Health Organisation was a serious error that had terrible consequences.
What is now required is a considered economic case for the primacy and viability of prevention. The focus of this must be this region, where a second HIV pandemic is just beginning. Prevention strategies must be the key priority to avoid a repeat of the African catastrophe. The basic economic structure of health systems must be reconfigured to create incentives to prevent – incentives every bit as attractive as those that already exist in the system to create care, treat and research. Those who say such a reform is impossible should contemplate the upheavals that are transforming the economic system in response to global warming. New systems of accounting, pricing and trading are being developed that will provide massive incentives to change behaviours and rebalance risk. New incentives to prevent will be created, and profits will accrue to those who do it best.
What is the difference between a molecule of carbon dioxide and a sliver of HIV virus? In economic terms, not much. Both are emitted, as it were, as by-products of human behaviours linked to the gratification of wants and needs. Both spread with no regard to borders, race, sex, gender, class, income, good intentions, age or any other human quality or attribute. Yet both can be controlled and contained by adjusting human behaviour. The difference between the response to global warming and HIV/AIDS is simply how we have gone about persuading people to make the necessary alterations in their behaviours. We accept that the surest way to manage global warming is to create and manipulate economic incentives, costs and prices. This is surely what must be done in relation to the future control of HIV.
There are great possibilities for restructuring health systems to provide incentives to prevent, to reward risk and achieve clear targets and goals. If we can provide the right incentives and rewards, and couple them with public health messages that make sense to the most vulnerable groups of young people, the spread of HIV will be controlled far more effectively than any punishment, prohibition, injunction, fatwa or prayer has been able to. When it comes to controlling and managing HIV, the lesson from the millions of a lost generation who died prematurely and painfully is that stern gods are less than useless. ♦