We Have Changed

One of the concerns in global health delivery is that certain diseases, especially HIV/AIDS, get more attention than others. This is an issue in terms of allocation of limited human resources as well. Within developing countries, there is often an exodus of health professionals from poorly paid public health posts to relatively lucrative NGO programs that often focus on one disease, such as AIDS. While there is much truth to this concern, there are two important points to be made. One is that the infrastructure put in place for an HIV program can be used as a platform to address other health issues. The other is that HIV/AIDS truly is an historic, unprecedented phenomenon. The following is a piece I wrote in this regard:

Any event that kills people on the scale of HIV is important, in terms of the number of lives affected. HIV/AIDS, with a death toll of 25 million, now rivals the other great plagues in history, such as the black plague of 14th century, or the 1918 Spanish Flu pandemic. But is it historic? If we define historic as a paradigm shift- that is, as an event that causes a radical change in global thinking, or a radical change in how people deal with each other- then the answer is yes, no, and maybe.
The emphatic yes to the question starts with the early days of the epidemic. Before HIV, marginalized people remained marginalized- at least from a public health standpoint. When tuberculosis had killed a broad spectrum of society in the 1930s and ‘40s, the urgency for tuberculosis therapy was greatly accelerated. But once it became exclusively a disease of the poor and indigent, it was largely forgotten; the last new drug for tuberculosis was developed in the 1960s. Malaria hasn’t been a concern for the United States in over a century. Even now, only 10% of health research spending is directed toward diseases or conditions that account for 90% of the global burden of disease (Global Forum for Health Research, 2000). But with HIV, something different did happen. Of the initial three groups of people affected by HIV, gay men, Haitians, and the IVDA population- all highly marginalized in US society, one made a particularly loud noise. Why did they succeed where others had historically failed?
If HIV had primarily affected gay men in Belarus, we might be having this discussion at a much later date. But the gay men affected were in the United States, where they had access to media (along with some political clout), and a ready tool to fight the scourge, US biotechnology. It is safe to say that if HIV had appeared on the scene 20 years prior, before the discovery of restriction endonucleases and the advent of genetic engineering in the 1970s, an even greater disaster would have struck. However devious the virus, its timing was not. Even so, funding for eventual therapy was slow to come. But attention wasn’t, as the gay men in America organized in extremely vocal and media savvy groups like Act Up (years later mirrored by Treatment Action Campaign (TAC) in South Africa). For example, AIDS activists were able to expedite drug approval by the FDA- decreasing time from drug application to drug approval from 34.1 months in 1986 to 12.6 months in 1999 (NEJM 344; 2001). And so a disease that affected marginalized groups entered global thinking.
The emphatic no to the answer of whether HIV is historic comes from the middle history of the epidemic. Once effective treatment became available in the developed world in 1996 with Highly Active Anti-Retroviral Therapy (HAART), the world fell into its old pattern. Marginalized and un-empowered groups- that is, the impoverished- didn’t have access to life-saving technology. Initially the drugs were prohibitively expensive, even for many in the US (over $20,000 per year). But within a few years the possibility of cheap generics became a reality. Yet the pharmaceutical industry fought the sale of low-cost anti-retrovirals, and were initially supported by other powerbrokers, such as many leading US politicians (including Al Gore), and trade groups. It was not until 2003 that the World Trade Organization (WTO) supported generics. Nearly 10 years later from their development, low-cost anti-retrovirals (ARVs) are finally arriving in sub-Saharan Africa, which carries two-thirds of the world’s HIV burden (UNAIDS, 2005).
The other half of the fight against HIV- prevention- is a complex tale. In this case, the fault of the slow response lay at the feet of the conservative nature of societies everywhere. Most adults have sex, and it is not a marginalized group being ignored in this instance, but an activity marginalized in public discourse. It is the fact that HIV is primarily sexually transmitted that has made prevention so difficult, and attached such stigma to the disease. Billboards promoting condom use now in Lusaka and elsewhere may mean a real change, but if not, HIV will follow the history of other sexually transmitted diseases- albeit, with unprecedented numbers.
Lastly, the big maybe in whether HIV/AIDS is historic is linked to the most recent years of the epidemic, and especially the future. This also ties into whether HIV deserves the attention it is receiving. In recent years, it has been shown that HIV/AIDS can be effectively treated in resource poor setting, in both small cohorts and on national scales. At first it was thought impossible, as the infamous comment by Andrew Natsios of USAID in 2001 illustrated: that in many parts of Africa “people do not know what watches and clocks are.” Dr. Paul Farmer, working in Haiti with an initial small group of patients, applied the lessons of DOTS (Directly Observed Therapy Short Course) from tuberculosis to HIV. He demonstrated high compliance with an anti-retroviral regimen, and 86% of patients had undetectable viral loads. These are numbers that rival the best HIV clinics in the United States. On a wider scale, the treatment and prevention programs of Brazil and Thailand also demonstrate the effectiveness of AIDS programs in developing countries. The Brazilian government mandated free ARVS in 1996, with universal access for their AIDS patients. Four years after the national treatment program was introduced, AIDS-related mortality fell 50%. In Thailand, a prevention campaign, the “100% Condom Program”, decreased incidence dramatically. In male military conscripts HIV incidence dropped from 2.48 per 100 person-years to 0.55 per 100 person years between 1991 and 1993 alone (AIDS; 12(5) 1998). And now the Global Fund to Fight AIDS, TB and Malaria (GFATM), the Presidents Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation and others are hoping to broaden these success stories.
It is crucial that they succeed, both in terms of the numbers of potential lives saved, and the possibility of changing the old paradigms. If they succeed, the story of HIV/AIDS will be one of how the rich world did pay attention to the poor world and was able to make a difference. This would be unprecedented for both public health and development. And so this epidemic does deserve the kind of response it is receiving. But if a child dies of malaria, is that any different then if it dies of HIV? No. But the fact is the world, for myriad reasons, has decided to pay attention to HIV. Before AIDS, there was no Global Fund to Fight Tuberculosis and Malaria. Tragically, we needed the A.