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Essay

Applying the paradox of prevention: Eradicate HIV

Shortlisted, Queensland Premier’s Literary Awards 2008, Science Writer Award

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.

THE GLOBAL RESPONSE has coagulated around an unexceptional negative proposition: the fight against AIDS. The trouble is that this fight has been hijacked by forces pursuing entirely different goals: the suppression of vice and the promotion of virtue. The decision-makers in the global struggle have deluded themselves that HIV can be contained only by a vast upheaval of deeply-rooted social norms and beliefs. Rather than focusing on the specific problem of preventing the transmission of HIV, we have been inveigled into a war against human nature. The consequences of these well-meaning but destructive strategies are now completely apparent. It is not possible to win a war against vice. It is ludicrous to pretend that the virus can be destroyed by denying the sexual lives of human beings. This is a virus, not a sin.

Since the late 1980s, the ostensible objective of the global HIV/AIDS strategy has been to mobilise opinion and resources behind a "war on AIDS". Who could not support such a fight? But the war on AIDS is compromised by the same linguistic flaws, political spin and hopeless confusion of means and ends as the other wars on abstractions: the "wars" on poverty, illiteracy, child abuse, discrimination, racism, cancer, terrorism, depression, crime and all the other ills of our times. Real wars against physical enemies corral every resource in pursuit of a clear outcome as rapidly as possible. In contrast, Orwellian wars on abstractions, including AIDS, are endless without achievable goals. The purpose of these "wars" is funding the perpetual struggle, not the elimination of the problem.

Surely, after a generation of intense effort, argument and expenditure, the outcomes should be better than they are? Why are the major indicators of the spread of the disease still increasing? Is it because of the inherent properties of the virus, or deep flaws in our strategic response?

After so many years of global failure, so many unnecessary and avoidable deaths, it is time to abandon the childish idea that we are engaged in a struggle against evil in the form of a virus. Rather, it is time to define a single, clear positive goal: the complete eradication of HIV from the planet. To achieve this goal will require a fundamental change in the present, confused global strategy that has failed either to meet the challenge of providing for the care and treatment of people with HIV and AIDS or, more importantly, to prevent the spread of the HIV virus.

It is time to separate HIV from AIDS both rhetorically and, more importantly, in substance; to distinguish the effort to prevent HIV infection from the vastly different challenges of caring and treating those with HIV infections and AIDS. Unless and until medical science produces a cure or vaccine for HIV, preventing transmission will involve educating people to make sustainable changes in sexual and other risky behaviours. Just as the prevention of cholera and typhoid in the mid-nineteenth century required engineering solutions, so the eradication of HIV requires some modest social engineering. Unlike physical engineering, however, social engineering is best done in the smallest possible increments; vaulting ambition leads only to failure and catastrophe.

For a time, it seemed sensible to see the problems of care and treatment and prevention as best dealt with as one within a single intellectual and organizational framework. But the urge to merge HIV and AIDS that occurred in the middle years of the epidemic can now be seen to have been a strategic error with seriously adverse consequences for the effective management of the global problem. The understandable desire to deal with all aspects of the pandemic within one framework prioritised care and treatment over prevention. These consequences were neither foreseen nor intended, but created an impressive moral hazard and a set of perverse incentives that is paradoxically now encouraging the global growth of HIV and AIDS cases.

The immense cost of providing universal access to care and treatment will inevitably require that the growth in new caseload be capped by successful prevention strategies. If HIV can be prevented, it must also, eventually, be able to be eradicated through a combination of behavioural and biomedical interventions. The case for the universal eradication of HIV within three generations – by the turn of the century – and for separating the responses to HIV and AIDS is based on the lessons I derive from the Australian experience of HIV. From the beginning we intuitively grasped the difference between dealing with the symptoms of the problem and the need to identify and overcome its causes.

I have had the onerous privilege of being involved in the development of Australian policy and the sobering experience of being on the receiving end of the some of the policies I helped to create. I have been around long enough to see the wisdom of Paul Keating's observation that successful policy-making is a fusion of guts and imagination – one without the other invites disaster. The goal of eradicating HIV, let alone containing its spread, cannot be realised unless we develop two separate but necessarily complementary strategies to prevent HIV and to care for and treat those with AIDS. Medical science alone cannot solve this problem; it will take more than the development of an elusive vaccine – a social vaccine is also required.

We should not be in this position, but we are. To get out of the mess, we first need to understand how and why we got into it. The pandemic is a function of the nature and properties of the HIV virus and the chaotic political response to its emergence or, to use Toynbee's structure, challenge and response.

 

VIRUSES ARE SMALL particles of matter that replicate by infecting the host cells of living things. A fascinating taxonomic debate exists about whether viruses are living organisms or simply a modified form of inert matter. Whether they are alive, or zombies, it seems likely that viruses emerged at much the same time as living organisms. While life became more complex, viruses did not. As the number and variety of living things and species increased, viruses colonised them, and continued to replicate. Viruses are constantly exchanged between humans and other animals. Generally, animal immune systems cope well with viral infections that might be disabling for a time, but rarely fatal to healthy individuals. However, immune systems and viruses are engaged in a perpetual struggle between offence and defence. Viruses mutate and evolve. A virus that is too weak to infect a new host will, of course, perish. But, from time to time, a virus evolves characteristics for which the immune system of a prospective animal or human host has no effective blocking response. In such cases, the new virus is free to infect and replicate without restraint and do immense damage to its unwilling host.

Understandably, we are most afraid of a highly infectious viral epidemic emerging without warning, and rapidly killing millions before exhausting itself. But from the point of view of the virus, there is such a thing as being too contagious. If too many susceptible hosts perish, or it encounters those who are naturally immune to it, the virus reaches its limits to growth. Fast acting viruses can be contained by quarantine. The far more insidious threat to human health arises from what might be called a Goldilocks virus – one that is not too weak, nor too strong, with just the right characteristics to allow infection and maximum replication and a long period between first infection and the onset of noticeable symptoms.

HIV is a Goldilocks virus. Paradoxically, it is its weakness which makes it so dangerous to humans. In its present form, HIV cannot be transmitted in saliva in sufficient quantity to infect new hosts. Transmissible quantities of the virus can only occur in the body's concentrated fluids – semen and blood. Therefore, only practices that involve the exchange or intake of infected blood and semen transmit the virus – and even then transmission is not certain. Once infected, individuals may not develop obvious symptoms for many months or years, although they are reproducing the virus and may be transmitting the infection. Left untreated, at some stage these people will develop one or more opportunistic infections, described as AIDS, and eventually weaken, sicken and die.

A clear understanding of the nature of the virus is crucial to its management in human beings. Prevention is possible only if we understand transmission, the core business of the virus. On the other hand, prevention is the business of humans. Prevention is political. The transmission and spread of any viral infection can, in theory, be controlled and contained. Highly infectious human carriers can be isolated or quarantined. Infected animals can be killed to prevent the spread of viral infections. All we need to know to control the spread of a new virus is where it lies on the scale of contagiousness, and what human practices are implicated in its transmission.

The twentieth century was book-ended by two great viral pandemics: the Great Influenza Pandemic of 1918-20 and the HIV/AIDS pandemic that began, officially, in 1981. The influenza pandemic claimed at least fifty million lives. The influenza virus was highly contagious. It was spread in air and by casual contact. Obvious symptoms almost immediately followed infection. It spread rapidly around the globe, accompanying the mass movement of American troops in the last stages of World War I as they moved among the displaced populations of Europe. But once authorities comprehended the nature of the problem and imposed appropriate containment policies, the pandemic burnt itself out. In contrast, HIV is not especially contagious. It spread slowly and, for a long time, imperceptibly. It was not spread casually but only in bodily fluids exchanged relatively infrequently.

Onset of symptoms followed many months or years after first infection. Its slow-acting, long-lasting nature made it much harder to identify, prevent, contain and manage than the 1918-20 influenza pandemic.

For all the scare-mongering and lurid headlines, there is nothing mysterious about viruses, evolutionary biology or the way viruses pass between animal species. HIV itself is a humdrum affair. It originated in central African primates and passed to humans some time last century. Thanks to its stealthy characteristics, it spread undetected in rural and remote Africa for years, perhaps decades, until the 1970s. By then it had reached a critical mass in terms of the numbers of people carrying it. Wherever semen or blood was exchanged, there was a route for transmission of the still-undetected virus. It was spread by sex and the use of infected needles for medical procedures and vaccinations, carried beyond Africa on waves of infected blood and semen.

Some time late in that decade, HIV crossed the Atlantic from Africa to America. It is most likely this was in the increasing volume of blood and plasma products being exported from Africa to the United States. The HIV epidemic had already claimed many African lives, but its pre-history counted from nothing when it finally hit the Big Apple. In 1981, the "first" case of HIV/AIDS infection came to notice in New York City among sexually active gay men. Until this point, the as yet undetected virus had been spread mostly by contaminated blood products and vaginal intercourse – and indeed the overwhelming majority of cases of sexual transmission have always been as a result of heterosexual intercourse. Its emergence within Manhattan's highly sexually active gay community was simply a random, chance event.

The timing and nature of this first appearance in America had catastrophic consequences for the subsequent course of events, both in the United States and globally. The speed with which a relatively minor viral disease became an uncontrollable global pandemic can be traced directly to the Americanisation of the virus.

Almost immediately it was first reported, the debate about its nature, causes and possible treatment became hopelessly enmeshed in the toxic stew of American domestic politics. The political struggle between secular liberalism and a resurgent fundamentalist Christianity had been simmering since the 1960s and erupted with great force following President Ronald Reagan's election in 1980.

The politicisation of AIDS transformed a problem into a pandemic. The search for facts about HIV/AIDS was overwhelmed by a pointless search for meaning. It became a cause and symbol to both sides of the American culture wars. America rebranded, repositioned and repackaged the syndrome for the world. It became the "gay plague", the "wages of sin" as foretold in Biblical prophecy. The myth of "innocent victims" was developed to account for the inconveniently large numbers of children infected by blood transfusions and the always significant number of women who acquired it from their heterosexual partners. Throughout the 1980s, America's political leaders ignored and discounted the emerging body of scientific evidence about the nature of AIDS. Instead, they listened to those who saw in it the workings of divine providence and a vengeful God.

Moves towards a rational and measured response were repeatedly swamped by the forces of religious reaction determined to associate it with the sinful trinity of homosexuality, prostitution and drugs. Effective prevention required official recognition of sexual activity and diversity, and illicit drug use. The religious right – which was flexing its political muscle with unprecedented force – maintained, however, that recognising this trio of normal human behaviours was tantamount to promoting them. As a result, under the Reagan presidency the government of the richest, most diverse nation in the world took no effective prevention measures at a time when it almost certainly could have stalled the spread of the virus.

It may have been tolerable if the consequences of this foolishness had been confined to the United States. But they were not. The first and greatest impact was in New York City, the media capital of the United States and the world. The cultural and religious conflict waged in the American media in turn greatly influenced global discussion and debate about the disease. AIDS was made for the American media. It involved exotic sex, illicit drugs, lurid exposés and hard-line religion. It provided titillation and provoked fear, anger, mawkish sentiment and noble suffering (depending on the prejudices of the journalist, editor and publication). AIDS in America had it all – florid fundamentalist preachers, dying Hollywood movie stars, outraged drag queens, preppy gay college boys, angelic children, spin-addicted politicians, distraught parents, harassed doctors, noble scientists and wasted and wasting artists, actors and playwrights. At a pivotal moment when so much could have been done, little actually happened. The sound and the fury signified nothing very much at all.

 

JUST AS AIDS arived in America with the election of a new government, it arrived in Australia in a similar context. The first Australian case was reported in Sydney just five months before the election of the Hawke Labor government in March 1983. The two new governments were radically different from their predecessors and from each other. They shared a similar economic agenda, but their social policies were completely at odds. Socially, the Hawke government was liberal-left leaning, while the Reagan administration was deeply conservative and reactionary. The dramatically different responses to HIV/AIDS reflected both the nature of our societies and the different political orientation of the two governments.

From its first weeks in office, the Hawke government and particularly Health Minister Dr Neal Blewett had to deal with this mystery ailment.

Public concern rose as increasing numbers of cases were reported among gay men in major Australian cities. American reports about the mystery illness were carried in the Australian media, initially without much local comment or embroidery. At the same time, the minister was busy with the tremendous political and legislative challenges surrounding the introduction of the Medicare system of national health insurance, a major election promise.

Nevertheless, from the earliest days of the new government, Dr Blewett and his office took a lively interest in the progress of the new disease. Almost every day it seemed there were more reports of the mystery illness appearing in America, and then Australia. At first, it seemed almost too exotically baroque to take seriously. But the closer it came to home the more concerned we became. Simply to demand information about the new disease was a crucial first step in the success of the Australian response. The minister assumed central government responsibility for handling what soon became a serious emergency and threat to public health. Contrary to the advice of the Department of Health, the new government was not prepared to leave the matter with the state and territory governments, or avoid responsibility for taking whatever steps might be necessary to respond to the problem. At the time, we had no idea how far and fast this assumption of responsibility would lead us along the path of radical policy innovation, bitter argument and controversy.

As senior adviser to the health minister, I became a focal point for everyone with an opinion about what was happening and what should be done. Throughout 1983, the situation became more confusing. The infective agent had not been identified. It appeared the caseload was confined to gay men.

But what exactly did the term "gay men" mean when it came to acquiring this ailment? The word "gay" was a political and cultural term adopted by homosexual men during the 1970s to elevate the rights debate beyond boundaries suggesting the claim to equal rights was based simply on certain sexual acts. It made as little sense to associate the term "gay" with "plague" as it would have been to talk of Liberal Smallpox, Republican Measles, Labor Headaches or Democratic Ulcers. Yet this is how the new malady was branded. This greatly complicated the task of determining what was going on, and what, based on the evidence, needed to be done.

In time, things became clearer. The viral nature of the illness was identified and a test was developed. It was found in bodily fluids but only seemed to be transmissible in the exchange of blood and semen – though, even then, not always. In their maddeningly precise way, scientists refused to assert that it was impossible for the virus to be transmitted by oral sex or kissing, which only increased concern. But given the commonality of both oral sex and kissing, and the complete absence of a caseload that would have developed had these practices spread the malady, we became more confident that it could not be spread by casual contact, or even quite intimate sexual behaviours. Over the following year, two schools of thought developed. One, shaped by the American debate, assumed it was at worst highly contagious and at best a gay-specific affliction that posed some risks to the entire community. Adherents to this view included some of the most senior health bureaucrats, politicians, presidents of medical associations, senior medical academics and a claque of religious leaders influenced by their American brethren and their media shills. They advocated a response based on sanction, isolation, punishment and quarantine, and highly repressive measures directed at the groups at greatest risk of infection: gay men, sex workers and injecting drug users (sparing the "innocent" haemophiliacs).

The other school included those closest to the problem: doctors, nurses and those caring for HIV-infected people, clinical scientists researching the virus, bureaucrats involved in the response, secular and religious social workers supporting various at-risk communities and, most importantly, those with the disease or at risk of contracting it. In the minister's office, we came to rely far more on the realistic and pragmatic advice provided by those closest to the problem than on the bombastic, prejudiced and often simply wrong advice of those remote from the problem as it was developing in our major cities. The policy challenge boiled down to the famous Groucho Marx question: "Who are you going to believe? Me, or the evidence of your lying eyes?" In the end, we chose to believe the evidence of our eyes.

By late 1983, gay men in Sydney and Melbourne had formed ad hoc support and information groups. They assured the government that it was feasible to promote the use of condoms for anal sex, and to persuade gay men to take reasonable risk-reduction measures. Sex workers and injecting drug users formed similar groups. Discussions with them also indicated a high degree of willingness to consider and advocate behavioural change, but only to the degree necessary to minimise the risk of HIV transmission. They made it clear there would be strong resistance to any measures to further increase the marginalisation of gay men, sex workers or drug users and that, in terms of reducing transmission, further oppression would be futile and counter-productive. The scientific evidence showed that the virus was not overly contagious, and our discussions with at-risk groups indicated that they comprised responsible citizens willing and able to educate their peers about moderating risky behaviours. What was required was a comprehensive national prevention strategy. Effective policies needed to be funded and applied and technologies provided to allow people to protect themselves and their partners from possible infection.

By the mid-1980s, we were satisfied that prevention was both theoretically possible and practically achievable. Minimising the risk of sexual transmission required the widespread promotion and distribution of condoms; minimising the risk of blood-borne infection required the blood supply for transfusions and in clinical settings to be routinely tested and sterile needles and syringes made available to those who were using drugs illicitly. By 1986 we were confident that the networks existed to disseminate information, advice and equipment and that a total commitment to HIV prevention should be tried and could bring about substantial and sustained reductions in new cases.

Yet the forces of resistance to prevention were also gaining in strength. They claimed that sustained prevention was not possible and at-risk groups could not be relied on to change their behaviour. They were opposed to the introduction of needle and syringe exchanges on the grounds that such measures would lead to an increase in drug use, and therefore an increase in new HIV infections. They were adamantly opposed to any measures that accepted the reality of homosexuality. The Catholic Church especially rigidly opposed the use or promotion of condoms, even to prevent infection in heterosexuals, and Pope John Paul II denounced what he called the "objective disorder" of homosexuality.

It was impossible and undesirable to reconcile these two positions. Either we opted for comprehensive HIV prevention or abandoned it entirely, as had occurred in the United States. In April 1987, the Australian government opted to support a radical package of HIV prevention measures. These policies comprised: timely, peer-based, direct and explicit preventive education campaigns directed both at high-risk groups and the general public; widespread introduction of subsidised needle and syringe programs and rapid expansion of methadone maintenance treatment; access to free, anonymous and universal HIV testing; subsidised access to anti-retroviral treatments; general advocacy of the need to adopt safer sexual practices, especially the use of condoms; and widespread availability of condoms and targeted safe sex messages.

These policies were in turn based on long-term thinking; the primacy of empirical research and evidence in making policy; the need to minimise risk to the general population; recognition of the importance of research, especially epidemiology, clinical treatment, retro virology and social science; respect for human rights buttressed as required by legislation; and collaboration and partnership between all stakeholders. The 1987 package funded the states and territories to deliver HIV and AIDS care, treatment and prevention services. It was the end result of a continuous social and political debate that had raged for four years. As in the United States, the debate was at times overwhelmed by the link between the virus and anal sex and injecting drug use, yet the evidence pointed to the feasibility and desirability of HIV prevention. This required the government to recognise the reality of sexual diversity and the widespread use of illicit drugs, and to confront the world as it was, not as some would wish it to be, and fashion pragmatic policies accordingly.

The package had been discussed by all the political parties represented in the Federal Parliament. With some notable individual exceptions, it was supported by them all and by all the states and territories, except the National Party government in Queensland. This put Australia's response to HIV/AIDS on a secure, long-term funding foundation. Major public education and information campaigns alerted Australians to the threat posed by HIV and told them how to prevent infection. Several clinical and social research institutions were funded, as were the main community organisations dealing with the disease. A national needle and syringe exchange program was introduced in every state, complemented by enhanced methadone replacement programs. Testing for infection was encouraged and covered under Medicare. Those with HIV and AIDS were given highly subsidised access to the latest treatments. Substantial legislative changes were made to protect people with HIV/AIDS from discrimination, especially discrimination related to employment and access to housing and other services.

This consolidated the progress in containing new infection rates among gay men and extended those gains to sex workers, injecting drug users and the general, heterosexually active, population. Rates of new infection, which had already started to come down in gay men, fell rapidly. Access to clean needles and syringes quickly reduced the worrying rise in infections among injecting drug users, and eliminated drug users as a vector by which HIV might have crossed over into the general population. Rates of testing and condom use increased dramatically. Tracking surveys indicated that knowledge about the disease, and the facts about its nature and transmission, improved considerably. Over time, incidents of discrimination against HIV-positive people decreased as ignorance and fear declined. Among high-risk groups, dedicated staff and volunteers worked tirelessly to spread the message about condoms and clean needles. The necessary financial and human resources were put behind a clear and unambiguous strategy. Annual rates of new HIV infections fell from 1,297 in 1988 to 986 in 1993. In 1998, the annual rates of new HIV infections in Australia fell to the historic low point of 645. Since then, the annual rate of new infections has increased to 928 in 2005 a rise that reflect the lack of sustained prevention campaigns directed at young people and perhaps a sense that HIV is no longer a mortal threat.

The shape of the epidemic in comparable countries is much the same. Rich countries have well-resourced health systems, easy and accessible mass communications, and community and non-government networks – all important factors in preventing and containing the virus's spread. Over the years, most Western countries brought down new infection rates by adopting broadly similar policies. The key difference is that Australia acted sooner, more decisively and more comprehensively, and was rewarded with a much lower overall toll of infections and deaths.

The policies funded by the Australian government in 1987 were those which, on the evidence, were already working best to contain the problem, or which offered reasonable chances of success in the future. As each intervention was tried, results were measured, analysed and reported. This was the classical application of scientific method as the basis for policy-making. We relied most for advice on those closest to the problem. We created advisory structures that encouraged bold, radical and innovative proposals without being compromised by bureaucratic timidity and nay-saying. And these proposals were then funded and implemented in the shortest possible time with the greatest possible impact.

Over the years, some critics have maintained that the Australian response was so atypical as to be almost unique, and that it could therefore not be applied universally. Certainly, the quality and nature of the political leadership at government level, and across the affected groups, was exceptional. Australian politics and society are generally non-ideological and pragmatic. Organised religion does not generally have much political clout. In the 1980s, the moves towards a less judgmental and more tolerant attitude towards homosexuality, sex work and even drug usage greatly helped in this policy-making and also helped shape a distinctively Australian response. But the qualities of the virus are no different in Australia than elsewhere. By its nature, the HIV virus is susceptible to simple prevention measures based in relatively minor changes to sexual and other risky behaviours. The Australian difference was the political will to inform, educate and to provide the necessary simple technologies: condoms and clean needles.

 

THE HIV PANDEMIC need never have happened. There is nothing inherent in the virus that made inevitable its transition from minor problem to global pandemic inevitable. The virus is relatively weak, not contagious and spreads slowly in human populations. The appalling truth is that the major driver of the spread of HIV was the failure of political will to translate scientific evidence into effective containment policies.

Within a few years of its first notification in the West in the early 1980s, medical science conclusively identified the nature and properties of the virus, devised workable – if not infallible – tests for its presence, and developed the first promising treatments for prolonging the lives of those infected. In the turbulent wake of the first explosion of cases, a thousand flowers of responses bloomed around the world. They ranged from executions of HIV-positive people, to repressive sanctions and quarantine and denial through to mass education, and practical and evidence-based policies based on prevention. Many governments were, and remain, reluctant to offend deeply held social, cultural and religious beliefs about sexual behaviour, drug consumption and sex work, especially among the young. Nevertheless by the end of the 1980s, it was possible to judge all of these responses and determine which had worked best to get new infection rates to sustainably low levels.

These outcomes were reported at the time to a plethora of international conferences, in specialised journals, government reports and the media. By the end of the 1980s, all of the information and evidence about HIV/AIDS that was needed to bring the incipient global pandemic under control and long-term management was available. The feasibility of preventing its spread had been demonstrated in Australia and The Netherlands and in large developing countries like Thailand. The emergence of effective treatments gave hope and incentive to those who might have been reluctant to come forward for HIV testing. The technologies that were crucial if prevention were to be sustained were cheap, and able to be widely and quickly distributed.

By 1990, the global caseload was only about eight million, most in Sub-Saharan Africa. Large areas of the globe, including most of the Asia-Pacific region (apart from Thailand) and Central Asia had been scarcely affected. There was, in short, a critical window over a decade from 1985 in which decisive preventive action could almost certainly have contained the global spread of the disease. The peer-reviewed evidence in favour of behavioural prevention was abundant and well reported at innumerable conferences, meetings and in scholarly journals. At all levels, credible experts pushed for major countries and the international agencies nominally responsible for dealing with HIV/AIDS to adopt rational and pragmatic harm-reduction policies.

The consequences of not acting to prevent the spread of HIV were clearly known and accurately predicted, yet those who should have responded did not do so. The failure of national governments and international agencies to act in time to avert the HIV/AIDS pandemic is both shameful and enraging. In the twentieth century, the world witnessed many examples of governments and politicians steadfastly failing to act in time to avert mass murder, death and destruction. Credible warnings were issued and ignored about the Holocaust, Stalinist Russia, Pol Pot's Cambodia, the Balkan Wars and the Rwandan genocide. The failure to intervene in time to prevent these tragedies cost millions of lives.

But, in its scale and scope, the global failure to contain HIV/AIDS has caused more deaths and suffering than even the worst of these appalling episodes. The catastrophe of the global HIV/AIDS pandemic is entirely the result of a failure to act on the basis of compelling evidence that was put before responsible policy-makers. In particular the global failure can be traced to the willful stubbornness and determination of the United States, the world's pre-eminent power, to pursue and advocate a response that had no basis in logic, evidence or reason. In the 1980s, the most trenchant, organised and concerted resistance to sensible containment policies developed among political and religious leaders in the United States supported by its ideological allies, especially the Vatican and staunchly Islamist states. In these quarters, the emergence of HIV was invested with religious and social meaning as a sure sign of divine retribution.

Such views are, of course, incompatible with the orthodox scientific explanation of HIV as a product of viral evolution. However, within a very short time after the emergence of HIV/AIDS, this "theological" explanation began to inform political decision-making. This view prevailed in the United States Congress and in successive administrations. For two decades, the United States government and its political allies opposed and stymied all international attempts to impose workable HIV prevention strategies based on science. American leaders opposed rational HIV policies based on their readings of Scripture and a morality that paid almost no heed to the realities of human behaviours.

At a time when so much could have been done to fashion a constructive global response, America used its weight as the largest contributor to the United Nations to undermine efforts within the World Health Organisation and other UN bodies to implement HIV prevention strategies and measures. For internal domestic political reasons, the American government created a massive split in the international response where, on the evidence, no disagreement was possible. This split over the nature and causes of HIV/AIDS prevented a global agreement on a single, coherent and effective strategy for containing the spread of the pandemic. It created strategic paralysis at the time when swift action would almost certainly have contained the problem. This failure was especially perilous in a globalising world, with rapidly expanding mass travel and the abandonment of general health checks and testing for travellers.

 

THE INTERNATIONAL PANDEMIC worsened during the 1990s. By 2000, the global HIV caseload had increased to well over thirty-two million people, four times the 1990 level Under a series of weak and inept Directors General and Executive Boards, the World Health Organisation failed to impose any coherent vision on the international response, especially in relation to prevention. In the mid-1980s, those voices within WHO who most cogently argued in favour of prevention were stifled. In 1990, WHO Director General Hiroshi Najakjima forced the resignation of Dr Jonathan Mann, the leading proponent of swift action to contain HIV – a disgraceful surrender of "official science" to political power. Thereafter, crippled by the timidity of its managers, WHO was unable to promote even simple harm reduction measures that provoked the opposition of the United States and its allies.

From 1993, the Clinton administration cautiously began to moderate American policies, and to seek ways in which a more sensible international response might be encouraged. However, it lacked political support in Congress, which remained under the control of Republicans elected on the votes of extreme religious fundamentalists. The Clinton administration was unable or unwilling to enact any large-scale domestic prevention policies of the sort that had worked in Australia and elsewhere. Under intense political pressure from the Republican Congress the Clinton administration could not proceed with well-advanced plans to introduce a national needle and syringe exchange program.

Nevertheless, by the mid-1990s the failure of political management of the global HIV epidemic was so glaringly obvious that it could no longer be ignored, even by the Americans. In 1996, strategic control of the management of the pandemic was removed from the incompetent purview of WHO and placed with a new specific-purpose United Nations agency, UNAIDS. Fifteen years after the first case was reported in New York, UNAIDS brought focus and a clear vision to the management of what had become a pandemic. Management structures were staffed by well-regarded technical experts and UNAIDS began the laborious process of collating, analysing and distributing information and statistics to member states and international agencies. It fulfilled an important fundamental requirement of the management of the HIV pandemic – a permanent, dedicated bureaucracy with responsibility for developing evidence-based strategies and recommendations for policies that might at least be considered by member states. Once it was established, and confidence in it grew, it became easier for member states to raise both interest and funds for the global response to HIV/AIDS. In the years since its inception, the total amount pledged to though UNAIDS for care, treatment, research and prevention in low– and middle-income countries increased from about US300 million in 1996 to over $US8 billion ten years later.

In 2002, the international response to HIV/AIDS was further improved by the decision of the G8 countries to create the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund is a public-private partnership that acts like a bank. It raises funds from governments and the private sector and distributes them to countries in accordance with transparent and rigorous guidelines that match investment against outcomes. The Global Fund was a large step away from the expensive, cumbersome and highly ineffective administration of program funds by the UN. The confidence of donors in the Global Fund is reflected in the increase in its funds under management to about $US10 billion by 2008.

There is no doubt that the creation of UNAIDS, and especially the Global Fund, have brought greater coherence and order to the international effort to manage the HIV pandemic, and to mitigate its worst effects. UNAIDS provides strategic direction and political leadership, while the Global Fund is a cost-effective administrator. Increased donor confidence has led to greatly increased funds, improved transparency and accountability in how it is spent. The quality of the experts and administrators employed is high; they are sharply focused on the problems at hand.

But no matter how effective these organisations might be, they are constrained by the money available, which in turn reflects the level of political support for their aims and objectives. After ten years of UNAIDS and five years of the Global Fund, the performance and adequacy of the international response to HIV/AIDS must be judged against outcomes.

These are decidedly mixed. Since UNAIDS was launched, the money available for HIV/AIDS in low– and middle-income countries increased twenty-eight times, from $US300 million to $US8.4 billion. However, the rate of increase in new funding is declining while the rate of new infections is rising. Pledges and commitments to fight the pandemic in low– and middle-income countries totalled $US8.9 billion in 2006 and $US10 billion in 2007, far short of meeting the estimated requirements of $US55.1 billion for the three years to 2008. By the end of 2007, the Global Fund expects to have received cumulative commitments of $US10 billion and to have distributed some $US6 billion in six funding rounds, over half to HIV/AIDS programs.

UNAIDS and the Global Fund have made progress expanding provision of care and treatment to the rapidly expanding global HIV caseload. By the end of 2005, some 1.3 million people in low– and middle-income countries were receiving anti-retroviral therapies. The Clinton Foundation has also played a valuable role in bringing down the prices of these drugs and thus getting treatment and care for more. But there is little prospect of sufficient funding becoming available to meet UNAIDS' target of anti-retroviral coverage for 80 per cent of urgent cases – more than 9.8 million people – by 2010. The overall shortfall means that the need to provide care and treatment has diminished the flow of resources available for HIV prevention. There is far greater political support for care and treatment than for prevention – at least the type most likely to produce the best results.

In recent years, the obdurate hostility of the American administration to rational HIV/AIDS care and treatment policies has faded away. To its credit, the Bush administration conceived a wide-ranging and comprehensive package of measures, the President's Emergency Program for AIDS Relief – known as PEPFAR. The establishment of the $US15 billion five-year program did not, however, resolve the fundamental disagreement over containment strategies, and most of the money goes to subsidise drug treatments. In 2007, the Bush Administration remains adamantly opposed to the promotion and wide availability of condoms. It refuses to support needle and syringe programs for fear of being seen to condone the use of illicit drugs. It counsels sexual abstinence or, failing that, monogamous marriage and fidelity as the only acceptable behavioural response to the disease. Only a fifth of PEPFAR funding is allocated to prevention, with at least a third of that spent on abstinence-based programs.

In this area, as with most other American policies, there are international consequences. Bilateral funding under PEPFAR is tied to recipients' support for abstinence and the "war on drugs". The Bush administration, and its supporters and allies, have opposed and undercut the adoption of harm reduction policies and promotion proposed by UNAIDS and other international forums. Significant American political leaders continue to oppose HIV/AIDS policies and institutions that do not conform to their proscriptions. American political leaders support President Bush's expansion of PEPFAR and the provision of large subsides to American pharmaceutical companies to increase access to new therapies. But among the major contenders for the American presidency in 2008 there seems little inclination to review opposition to simple behavioural prevention, either at home or abroad.

American public funding to HIV/AIDS is now matched by private funding which encouragingly supports rational and evidence-based approaches to prevention. The establishment of the Bill and Melinda Gates Foundation has brought new resources and highly capable management to HIV/AIDS research and innovative HIV programs, and the Clinton Foundation has also played an important role. Compared to the global position a decade ago, the amount of money directed at HIV/AIDS is at last achieving critical mass. But the key indicators of how well the pandemic is being managed are not simply the total level of funding (although funding is, of course, crucial), the number of strategy documents produced or signed by agencies and governments, or the regurgitation of pious calls to action by the great and the good. Rather, the key indicators are the global caseload, the annual number of new HIV infections – especially in relatively unaffected countries and regions – and the rate at which new infections are rising or falling. These indicators are not satisfactory.

In terms of care and treatment, the indicators of success or failure are the number of people urgently requiring anti-retroviral treatment against those actually receiving the therapies. Although the funds devoted to HIV/AIDS have increased substantially – albeit off a low base – the money is still insufficient to meet urgent demands for HIV/AIDS treatments in 2007, and the global caseload is still rising. By December 2006, an estimated forty million people were living with the virus. In that year alone, three million people died from AIDS and more than four million people were newly infected – half of them under twenty-five. The preponderant HIV caseload remains in Sub-Saharan Africa, but the disease is expanding rapidly into Russia, East and Central Asia and Eastern Europe. Between 2004 and 2006, the number of new infections in Eastern Europe and Central Asia more than doubled.

 

THE HIV PANDEMIC now poses a great threat to the largest, most populous and economically dynamic region on earth, the Asia Pacific. In 2006, India had an estimated five million people living with HIV/AIDS (although recent reports suggest this may be too high) and China an estimated (incompletely reported) HIV caseload of more than half a million people. The overall prevalence of HIV infection in East and South-East Asia remains at less that 0.1 per cent, indicating that there is still a window of opportunity for effective preventive action to be taken in the region as a whole.

The impact of the HIV pandemic in the Asia Pacific region varies widely between and within countries. Of particular concern to Australia is the rapid spread of HIV infection in Papua New Guinea with nearly 2 per cent of all adults and up to 3.5 per cent of those living in urban areas – a rate approaching that in Sub-Saharan Africa. New HIV diagnoses have increased by a third each year since 1997. The very high level of infection in Papua New Guinea raises concerns about the potential for the rapid onset of HIV infection of neighbouring Melanesian societies, including West Papua, East Timor, the Solomon Islands and other Pacific island states even into the Torres Strait Islands and Northern Australia. Recent anecdotal and other reports suggest that HIV prevalence rates in some parts of West Papua and Irian Jaya may be approaching those in Papua New Guinea.

In 2007, we confront a serious disconnection between the substantial increase in resources being devoted to HIV/AIDS and the greatly improved management structures devoted to allocating and distributing these funds, and the evident failure to contain the growth of new HIV infections. The root cause of this failure remains – as it always has been – a deep, trenchant reluctance to embrace effective HIV prevention policies and measures.

It is obvious that if the HIV caseload is increasing, then prevention measures have not, on a global level, worked. Have behavioural prevention measures not contained the spread of HIV/AIDS because they cannot work? Or is it because they have not been undertaken with sufficient funding, force and vigour? Since the experience of a number of countries, including Australia, has demonstrated that HIV prevention is possible and sustainable, then the failure to prevent and contain HIV/AIDS must be a result of the failure of strategy and implementation. At the heart of this is the continuing paralysis of the political will needed to implement effective prevention measures and policies.

THE FAILURE TO control what has become a pandemic stems from the fundamental political and ideological divide which opened up in the earliest years of the epidemic, and which remains unresolved. Prevention requires authorities to come to terms with the realities of sexual diversity and, to a degree, the injection of illicit drugs by young people. If the realities of such behaviours are openly and honestly acknowledged, then prevention of transmission is possible. But if governments are unable or unwilling to accept these social realities, then prevention becomes very difficult to achieve and to sustain.

Those who naively declared "war" on HIV/AIDS in the 1980s very rapidly came into conflict with the aims and objectives of two other "wars" – the "war on drugs" and the "war on sex". The "war on drugs" was proclaimed by the United States in the 1970s. The use of illicit drugs is dangerous and ought always to be discouraged or reduced. No responsible parent of politician would think otherwise. But this "war" concentrated on the reduction of supply, without any coherent domestic effort to minimize demand or reduce harm. Successive administrations have devoted billions of dollars to futile attempts to eradicate the feedstock and supply of various forms of narcotic drugs – from opium poppies to cocaine. Notwithstanding its position as the world's greatest consumer of illicit drugs, the United States maintained an official position of "zero tolerance". It was therefore impossible for the government to condone any policy shift that might be seen as being "soft on drugs". Zero tolerance of drugs meant high tolerance of HIV and AIDS.

The war on drugs is comparatively recent; the "war on sex" has very ancient roots. The Catholic Church is its institutional vanguard, but the values that underpin it are shared by fundamentalist Islam and evangelical Protestantism. When AIDS emerged, the hierarchy of the Catholic Church immediately realised that the use of condoms to prevent HIV transmission would subvert its opposition to the use of condoms for contraception. Despite substantial pressure from laity, clergy and senior prelates, the Catholic Church maintained its official proscription to the use of condoms for any reason, including HIV prevention. In the two decades of the HIV pandemic, the Church hardened its doctrinal opposition to homosexuality, drug use and prostitution. It increased pressure on the governments of countries with large Catholic populations not to sanction effective HIV prevention policies. The emergence of AIDS led the fundamentalist variants of Christianity, Islam and Judaism to form a broad religious and political front in the "war on sex".

For over two decades, the UN and its specialised agencies have been a major battleground for these brawls.. The foundation of UNAIDS in 1996 gave some hope that the balance would tip in favour of large-scale, effective international HIV prevention policies. Yet these hopes were fulfilled more by rhetoric than in practice. This is hardly surprising. The UN and its agencies are, in the end, creatures of and subject to the political forces exercised by and through its member states and largest donors. Throughout the 1990s, the United States, the Vatican and its ideological allies pursued their wars on drugs and sex through the UN. This inevitably affected the drive and commitment of the agencies to support large-scale, effective prevention programs and their willingness to confront political opposition to such programs.

 

AS BITTER AS this split was, it at least had the merit of being obvious. The lines between the opposing points of view were clearly drawn. Over time, the consequences of not providing condoms to prevent transmission became apparent when judged against the results in those countries where they were widely distributed. Despite the "war on drugs", many countries embraced harm-reduction policies and adopted needle and syringe exchange programs to contain HIV infection among injecting drug users. Gradually, the accumulation of scientific evidence in support of effective prevention began to wear away at least the intellectual foundations of these misbegotten wars. Nevertheless, religious and ideological opposition to behavioural prevention has not abated. Despite – or perhaps because of – the accumulation of evidence in support of prevention, the Catholic Church remains implacably opposed to the promotion and distribution of condoms, and the Bush administration refuses to condone or sanction any form of harm reduction in relation to the use of illicit drugs.

In the last decade, however, behavioural prevention has also been increasingly discounted from a more unexpected direction – from sections of the scientific and medical establishment. In 1996, the first highly effective AIDS drugs were introduced. Since then, a new conventional wisdom has emerged within some elements of the medical and scientific community that discounts prevention as either achievable or practical. This school of thought has been greatly influenced by the development of very effective new antiretroviral treatments. Over these ten years, medical science has brought to the market therapies that have greatly reduced the viral levels of HIV-positive people, significantly delayed the onset of AIDS illnesses and generally restored reasonable health and wellbeing to infected people who have access to the treatments.

These new therapies, have of course, been unalloyed good news for those with HIV and a tribute to the excellence of the science and research that created them. Generally, better treatments means that people have an incentive to be tested. Knowing one's status is important in securing treatment and delivering prevention information and advice. Far better outcomes are likely if people agree to be tested without being coerced in ways that increase stigma or discrimination. The reduction of stigma, fear and discrimination assists, rather than hinders, control and management.

Development of these treatments has led many scientists and researchers to conjure the attractive prospect of HIV/AIDS becoming a long-term, manageable condition – perhaps equivalent to diabetes. Politically, the emergence of effective treatments offered a seemingly happy third way between the protagonists of the great cultural and religious conflicts that marked the early years of the pandemic. While there was bitter and irreconcilable division about how the spread of HIV could or should be prevented, almost everyone agreed on the need for increased funding and support for care and treatment.

A broad coalition advocating care and treatment emerged that encompassed hitherto opposed groups and factions. Catholic and other churches supported treatment provided through their hospitals, clinics and as part of their pastoral mission, especially in Africa and Asia. Naturally, the growing millions of infected people demanded access to treatments and pressured their governments to provide them. The great pharmaceutical companies, which had invested vast amounts of money in research, properly sought returns to satisfy their shareholders and investors. The roles of doctors, nurses, carers, scientists and clinicians were all reinforced and enhanced by the need to test, provide, administer and assess the new treatments.

The emergence of this wide and broad coalition for care and treatment was welcome news for harassed politicians and bureaucrats. Instead of pitched cultural and religious battles over prevention, garnering money and political support for care and treatment promised a quieter, less confrontational and more satisfying life. The politics of popping a pill into a patient were preferable to negotiating the treacherous political quicksands of sexuality and drugs.

Yet this apparently more benign framework created a dangerous new set of perverse incentives that now distort the global management of the HIV pandemic. Most of the billions of extra dollars devoted to HIV/AIDS in the last decade have been absorbed by drug companies, doctors and the medical system for care and treatment. Over this decade, the results are both spectacular and depressing. In a perverse way, funding care and treatment is contributing to the uncontrolled growth of the pandemic – not in any deliberate way, of course, but that is the effect. If we pay billions to care and treat, we can hardly be surprised if caseloads rise. If very little goes into prevention, we can hardly be shocked that the spread of HIV continues unchecked and uncontrolled.

This situation is dangerously dynamic and inherently unstable. It is based on assumptions that fail even the most elementary critical scrutiny. The idea that new and effective treatments for HIV will somehow contain the pandemic is wrong, yet the new consensus, backed by billions of donor dollars, creates the illusion that the pandemic is being contained. This might be comforting, but it remains an illusion unsupported by evidence or logic. If we want HIV/AIDS prevention to work, we will have to pay for it, and do it properly in the both the developing and developed worlds.

The present global caseload is forty million. It is growing at a conservatively estimated rate of four million cases, or 10 per cent, each year. The sheer size of this caseload poses new forms of general health and financial risks. It is increasingly clear that the world cannot afford the real costs of treating even the present caseload, the sheer size of which is transforming the nature of the threat it poses, with immense new costs on national economies and the international system. The costs of providing anti-retroviral therapies to even a significant proportion of a global caseload that may number eighty million people within a decade are staggering, and have not yet fully been assessed by UNAIDS' actuarial calculations.

Assuming, conservatively, that each course of therapy costs $US1,000 per person per year, the cost quickly reaches into the billions of dollars even before accounting for the expanded human and capital infrastructure required to deliver it, or the opportunity costs involved in treating HIV/AIDS at the expense of other priorities. Notwithstanding the good intentions of the UN, the harsh political and economic reality is that these costs are beyond the capacities of governments and donors to fund without diverting resources from other critical development areas.

A large and growing caseload also increases the threat that the HIV virus will both increase its resistance to drug therapies and facilitate the spread of new strains of dangerous pathogens, especially highly drug resistant tuberculosis. These new strains of tuberculosis are dangerous to people with HIV/AIDS and risky to otherwise healthy individuals. Already, outbreaks of extremely drug resistant tuberculosis have been reported in South Africa, South Korea and the United States. In Cambodia, which has brought its rate of new HIV infections under some control, more than half those living with HIV/AIDS have tuberculosis of one form or another.

 

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.


From Griffith Review Edition 17: Staying Alive © Copyright Griffith University & the author.

Griffith Review