2008_01_01_archive

The virtues and perils of putting HIV/AIDS into perspective

It looks like 2008 will be a strange year in HIV/AIDS circles. The

prospects of controlling the rise of new infections have been dimmed:

2007 was marked by a series of painful setbacks in HIV prevention

research, particularly in regard to microbicides, diaphragm and

vaccines. Estimates of the scale of the epidemic have been redrawn:

the numbers of persons living with HIV/AIDs (most notably, in India)

are still in the tens of millions, but found to be substantially lower

than previously estimated by the World Health Organization and UNAIDS,

raising doubts about these organizations and their statistics. Last

year also saw the publication of two high-profile books by Helen

Epstein and James Chin that took dead aim at flaws (and some sacred

cows) in HIV-related research, policies and programs.

Continuing the dark trend into the New Year, Daniel Halperin has

written a New York Times editorial ('Putting a plague in perspective')

that gives voice to a very real concern, namely that more mortality

and morbidity in developing countries could be reduced if some of the

billions of dollars currently devoted to HIV/AIDS in developing

countries were spent on other things, such as clean water provision,

nutrition or less fashionable (but no less serious) diseases. The

pendulum seems to be swinging: since the beginning of the epidemic

there have been continuous and passionate calls for greater financial

resources to fight against HIV/AIDS from researchers, activists and

policy-makers. And their calls have gradually been answered, to the

extent that there is now talk of HIV/AIDS being an industry in itself,

with its own big agencies (like UNAIDS) and big programs (like PEPFAR

and the Global Fund) and big conferences (like CROI and the World AIDS

Conferences). But now it looks like a new zeitgeist has arrived, where

HIV/AIDS is starting to be viewed as one important global health

priority among others. A big killer, yes, but no longer the king of

the jungle.

There is an important truth in Halperin's perspective. The struggle

against HIV/AIDS should be embedded within a larger political and

ethical struggle to raise the health and well-being of populations in

developing countries generally. Millions of people continue to live

their lives in absolute poverty, millions of people die annually of

preventable and treatable diseases, and the gulf between the affluent

and the poorer nations is widening. The point of 'putting the plague

in perspective' is not to downplay the significance of HIV/AIDS as a

worldwide public health problem, but to expose global inequality and

injustice, and to develop effective research, policies and programs

engaging with the most pressing needs of communities.

But at this point, a skeptic may wonder. Will this expanded vision

sell? How many funders be interested in combatting (very unsexy)

diarrhea in Tanzania? Where are the activist groups for leishmaniasis,

schistosomiasis and onchocerciasis? Can we imagine the US Congress (or

the European Union, for that matter) approving billions to something

so mundane as water improvement in Malawi or combatting deforestation

in the Congo? And what, ultimately, is the difference between what

Halperin is saying and those in development circles have been trying

to do for decades, and which has hardly been a glowing success in

Africa? From this skeptical perspective, 'putting the plague in

perspective' is like going from the frying pan to the fire: if you

think HIV/AIDS is bad, wait until you see the larger picture of

long-standing and intractable problems.