An excerpt from
Global AIDS: Myths and Facts
by Alexander Irwin, Joyce
Millen and Dorothy Fallows
Myth: The best way to control AIDS in the developing
world is by putting all available resources into stronger
prevention programs. In developing countries, costly treatment
for people already infected with HIV should wait until
prevention programs have been fully funded and deployed.
Response: Until the mid-1990s, the public health
battle against AIDS in both rich and poor countries focused
almost entirely on efforts to prevent new HIV infections,
because no effective treatment for AIDS existed. Prevention
during the first 15 years of the epidemic gradually grew more
sophisticated: from behavioral education and condom promotion,
HIV counseling and testing, to the treatment of sexually
transmitted diseases (STDs) that can facilitate HIV
transmission, and the blocking of mother-to-child transmission
of HIV with drugs such as AZT.
Advances in knowledge have strengthened the response to
AIDS, yet, with each increment in technology, the gap between
rich and poor has widened. In 1996, when highly active
antiretroviral therapy (HAART) was introduced at the XI
International Conference on AIDS in Vancouver, the gap became
a chasm. In North America and Europe, HAART dropped AIDS
mortality rates dramatically and improved life quality for
people with AIDS.2
At a cost of more than $10,000 per patient per year, HAART
became and remains the standard of care for AIDS in wealthy
In developing countries, where the world's HIV/AIDS burden
is concentrated, a different standard applies. Though the cost
of antiretrovirals (ARVs) has decreased sharply, more than 90
percent of people with HIV/AIDS remain without access to these
lifesaving drugs. The worldwide struggle against AIDS has
become a two-tiered system. While people in high-income
regions (along with developing-world elites) enjoy access to
effective antiretroviral treatment, public health authorities
in low-income countries are advised to concentrate exclusively
on prevention, and avoid the technical challenges and expense
of treatment programs.
This two-tiered strategy on HIV/AIDS has powerful defenders
among academics, public health experts, and leaders of some of
the world's most influential international health and
Writing in the pages of scholarly and medical journals, many
experts insist that for the foreseeable future, a choice
between prevention and treatment will be unavoidable for poor
countries because of the inadequacy of global AIDS funding and
the weakness of many developing countries' health care
While respecting many of the scholars and health experts
who defend this view, we disagree with their claims. We join
the growing number of voices -- represented by groups of
people living with HIV/AIDS, various NGOs, and health care
providers -- who are challenging the prevention vs. treatment
Prevention of HIV and treatment of those suffering from the
disease should not be seen as mutually exclusive, but as
mutually reinforcing, complementary arms of a comprehensive
global AIDS strategy. The following considerations argue for
the immediate scaling up of prevention and treatment:
(1) moral and social implications of denying treatment to
millions of people already infected; (2) the structural limits
to the efficacy of prevention programs when no treatment is
available; (3) the evidence of synergy between HIV prevention
and treatment, and (4) treatment's role in providing political
leverage for AIDS control, including stronger prevention
Moral and Social Crises
By recent UNAIDS estimates, more than 42 million men,
women, and children are living with HIV and AIDS worldwide. At
current rates, each day more than 15,000 people are newly
infected with the virus and 8,000 die. The vast majority of
people with HIV/AIDS live in the developing world and
currently have no access to medical treatment for HIV disease
itself or for the opportunistic infections associated with
A strategy that emphasizes prevention to the exclusion of
treatment offers no hope to these tens of millions of human
beings. In fact, it passes a death sentence on them. One
international official, speaking anonymously to the Washington
Post, put it bluntly: "We may have to sit by and just
see these millions of people die."
Such a position may be seen as public health realism. Yet
realism of this type contradicts the basic principles of
equity and human rights and acquiesces to what has been called
a system of "global medical apartheid."
The apartheid analogy has been drawn by people who fully
measure its resonances. Among them are leaders of South
Africa's Treatment Action Campaign (TAC), many of them
antiapartheid veterans, and South African Supreme Court judge
Edwin Cameron, an HIV-positive man who also struggled publicly
against apartheid and now stands in the front ranks of the
AIDS fight. Cameron argues that "the moral choices of the
1980s," which pitted people of conscience against South
Africa's apartheid government, are "replicating
themselves in a different form in the 2000s" in the
battle for equal access to AIDS treatment.
A first step toward altering the existing injustice is for
the voices of poor people with AIDS to be heard. Increasingly
today, activists living with HIV/AIDS from the developing
world are speaking out, claiming a role in shaping
international AIDS policy. They demand that decisions about
such issues as the apportioning of funds for prevention and
treatment no longer be made without consulting the people most
directly concerned: people living with the virus, the vast
majority of whom are poor. People living with HIV/AIDS
"are 40 million strong and growing, and they are not
telling us to concentrate all of our AIDS activities on
prevention. ... They are not arguing that costly therapeutic
interventions are not 'sustainable' in poor settings, not
'appropriate technology' for low-tech areas of the
Matthew Damane, a 25-year-old South African man from the
township of Khayelitsha, outside Cape Town, receives ARV
medications through a pilot program run by Médecins Sans
Frontières (MSF) and the Treatment Action Campaign (TAC).
Damane has drawn national and international attention as a
spokesperson arguing from his own experience that AIDS
treatment can be effectively implemented in resource-poor
settings, and that poor Africans can indeed learn to comply
with complex drug regimens:
Because I have been helped so much by this medication, I
wish I could share it with all the others in South Africa who
face the same problem. Recently I went with a delegation of
people from MSF and TAC to Brazil. We imported some generic
antiretroviral medicine in defiance of the drug company
patents. ... In Brazil, I saw a country that is not rich, but
everybody there has access to antiretrovirals. That has the
effect of reducing the stigma and bringing down the rate of
infection. South Africa could do the same. ... The MSF
programme, which is a trial providing antiretrovirals to
people in Khayelitsha, is working very well. It shows that
people living in poor squatter communities can take the drugs
properly and benefit from them. There are just millions more
people waiting in the queue.
Another resident of Khayelitsha receiving HAART through the
MSF program echoed these sentiments: "People must know
that a poor person like me living in a shack can take these
drugs properly. They are my chance to live."
Advocates of a prevention-only approach to HIV/AIDS in
low-income countries argue that providing ARV treatment is not
cost-effective in poor regions. A year of productive life can
be gained in sub-Saharan Africa at a cost of about US$l, using
HIV prevention strategies such as condom distribution and
blood product screening in hospitals.
To gain a year of life with adult antiretroviral therapy will
cost hundreds of times more.
Yet cost-effectiveness is only one factor to be examined in
weighing clinical strategies.
Ethical and humanitarian aspects also demand consideration.
Moreover, as a physician who administers HAART to patients
in the MSF pilot program has argued: "Narrow
cost-effectiveness analyses of AIDS treatment in developing
countries promote a medical ethic that would never be
considered in the developed world." Rich countries apply
cost-effectiveness analyses only very selectively in
evaluating health care options. For the privileged to advise
those in less-developed countries to adopt cost-effectiveness
as their exclusive criterion in HIV/AIDS control is
addition to the moral problems raised, a prevention-only
strategy fails to take seriously the overwhelming social and
economic costs for countries with high HIV prevalence. Many of
these infected people will die of AIDS in the midst of their
most productive years of work and parenting, generating
enormous losses not only for individuals and families, but for
society as a whole.
Plummeting numbers of teachers, medical staff, and farmers
have been already documented in the hardest-hit countries.
The generation of orphans to AIDS is growing exponentially,
and four decades of gains in infant mortality and life
expectancy have been lost to HIV in many African countries.
(For further discussion, see Myth 8.) Providing treatment to
infected people, enabling them to continue fulfilling their
parental responsibilities and contributing to society through
work, will bring important social and economic payoffs. As Dr.
Peter Piot, head of UNAIDS, has argued, prevention efforts
will help save people from falling prey to infection in the
future. But people, societies, economies, and whole countries
are in urgent danger now, because of the threat of millions of
premature deaths, and "only treatment can change that
trajectory." The quality of the future that awaits
numerous high-burden countries depends heavily on the quality
of life they are able to provide to their HIV-infected
citizens in the present.
The Limits of Prevention
The prevention of new HIV infections must be the
cornerstone of a comprehensive global AIDS strategy. Yet there
are limits to what prevention efforts can achieve. Notably,
though AIDS education and prevention have been underway in
many countries since the 1980s, the spread of HIV has not been
halted, and indeed has worsened steadily in many areas. While
numerous moderately effective prevention initiatives and some
dramatic successes can be cited, such victories are
Inadequate support for prevention programs explains a
substantial part of this failure. In 2001, a prevention
leadership forum sponsored by several major foundations
pointed out that "less than $1 billion is spent each year
on HIV prevention programs in low- and middle-income
countries," despite UNAIDS estimates that between $4 and
$5 billion annually would be needed to sustain an effective
global HIV prevention campaign.
Constrained budgets have meant that effective but relatively
costly prevention measures -- e.g., voluntary testing and
counseling, treatment for STDs, and prevention of
mother-to-child transmission of HIV using maternal
antiretroviral therapy -- have scarcely penetrated the poorest
and most heavily burdened areas.
Yet, even where relatively vigorous prevention programs
operate, structural obstacles often limit their effectiveness.
Early programs focusing on individual behavior change (for
example, condom use) proved largely ineffectual in many
settings. In recent years, some public health practitioners
and scholars have shifted their attention to structural and
environmental factors influencing people's ability to
implement prevention messages. Important gains in knowledge
have been achieved, and a growing "structural-factors
literature" has emerged.
Yet this effort is relatively new, and numerous gaps in the
research remain. Moreover, understanding how social and
economic factors determine individuals' vulnerability to
infection does not necessarily mean public health officials
will be able to alter these patterns. As discussed in Myth 2,
prevention strategies continue to clash with relentless social
and economic pressures, including the effects of poverty,
class disparities, structural racism, and gendered power
On matters such as condom use, carefully crafted,
culturally appropriate programs are needed both to empower
women and to change attitudes among men. Yet even the best
planned initiatives -- informed by social science research and
relying on peer educators -- often meet with frustration.
Individual risk behaviors are framed by a predisposing social
context whose mechanisms escape the control of at-risk
individuals and AIDS educators alike. Social obstacles and
economic constraints must be negotiated before ordinary people
can translate prevention theory into practice.
In areas where the epidemic has already gained a powerful
hold, with adult prevalence rates reaching five percent or
higher, conventional prevention strategies, even good ones,
bring limited success. Once the epidemic has moved out from
relatively focused high-risk groups into the general
population, fully containing the spread of infections becomes
virtually impossible. This is the current situation in many
high-prevalence countries. Most HIV-positive people remain
asymptomatic for years, so they can unwittingly transmit the
virus to numerous others before learning they are infected.
Under such conditions, traditional education and prevention
campaigns can bring new infection rates down, but will not
reduce them to zero. Even where prevention scores victories,
as in Uganda, the epidemic continues, and the question of
treatment for infected people demands to be addressed.
HIV prevention and treatment for people with HIV and AIDS
are not mutually exclusive options. On the contrary, a growing
body of evidence suggests that the availability of treatment
actually advances prevention goals. Prevention and treatment
support each other.
This synergy is clearest in the area of voluntary
counseling and testing. Widespread HIV testing that gives
people knowledge of their status is a cornerstone of effective
prevention programs. When HIV-positive people are aware they
are infected and receive appropriate counseling, they are
better able to cope with the disease and to take action to
protect their partners from infection. Similarly, people who
know they are HIV-negative, especially in a high-prevalence
area, find encouragement to reduce risk behaviors and maintain
their health. Thus, voluntary counseling and testing programs
have been shown to be one of the most effective prevention
Voluntary counseling and testing has been a pillar of
Uganda's widely admired AIDS control program, as a means of
fostering a collective response to the epidemic and bringing
both seropositive and seronegative people into the system for
counseling and support.
The role of voluntary counseling and testing is expanding in
the US through the CDC's new campaign: a Serostatus Approach
to Fighting the Epidemic (SAFE).
Its efficacy and cost-effectiveness in promoting risk-reducing
behaviors has been demonstrated in randomized control trials. For
example, testing women of reproductive age is a critical part
of programs to prevent mother-to-child transmission.
However, broad-based community participation in voluntary
counseling and testing is often difficult to achieve.
Discrimination against HIV-infected people discourages many
from seeking testing and counseling services.
Fears of stigmatization and the possibilities of domestic
violence and desertion by husbands and family are strong
barriers to women.
Hopelessness and fear of dying also discourage participation.
In a study in Zambia, many people who did not want testing
said they were probably infected anyway, and since there was
no medical help for them, it was better not to know.
Where a significant number of people in the community already
have AIDS, fatalistic attitudes are easy to understand.
Without access to medical treatment, people may have much to
lose by knowing their status and very little to gain. The
psychological stresses are high not only on people undergoing
the test but also on counselors.
Emotional difficulties such as anxiety and depression have
been reported among health care workers in AIDS-endemic
regions where no therapy is available to offer patients.
In such contexts, both counselors and prospective HIV test
subjects may feel that an HIV-positive diagnosis amounts to a
New approaches are desperately needed to encourage
acceptance of voluntary counseling and testing. Linking it
with access to life-saving treatment offers real hope and
provides a clear incentive for testing, greatly strengthening
AIDS control programs. When ARVs are offered, people have
something important to gain from voluntary counseling and
testing, whatever their test results.
Research has also shown that access to AIDS treatment can
help reduce the stigma associated with HIV infection.
Over time, the availability of effective treatment modifies
the social perception of the disease. This effect has been
observed not only in the US and Europe, but also in rural
Haiti. In the years before effective treatment, the uniformly
fatal infection often inspired reactions of terror; people's
fears of the virus spread to include individuals infected with
it. In recent years, the availability of therapy has changed
the situation by bringing about what has been called a
"normalization" of HIV disease. Stigmatization and
discrimination have been reduced, so HIV/AIDS can now be dealt
with as a more straightforward, "normal," medical
In wealthy countries, AIDS is now thought of by many as a
chronic disease rather than as a death sentence. The greatly
increased numbers of people seeking voluntary counseling and
testing in low-income settings where treatment has been made
available have confirmed the synergy between prevention and
treatment. This effect has been observed in Brazil and in a
pilot HAART programs in rural Haiti and in South Africa. At
the Haitian clinic, use of free HIV counseling and testing
services increased by more than 300 percent after the
introduction of antiretroviral treatment for qualifying
patients. An MSF program in South Africa saw a rise of over
1100 percent in the number of people voluntarily seeking
testing after ARV therapy was introduced.
Another public health consideration for expanding access to
AIDS treatment is that ARV therapy may reduce the level of
infectiousness. The evidence is mainly indirect, but
convincing. Antiretrovirals act to suppress active replication
of the virus and have been shown to reduce viral load in blood
Decreased viral load has been associated with lower risk for
transmission of HIV infection.
Unfortunately, easy access to ARVs in the absence of strong
prevention programs can introduce new dangers, both for
individuals and populations. While viral loads in patients
undergoing treatment may fall below "detectable"
levels, it does not necessarily fall to zero.
The risk of infection through sex with a person undergoing
antiretroviral therapy treatment is reduced but not
eliminated. This may not be fully appreciated by the wider
population; alarming new trends in parts of the US and Europe
show a decrease in the level of safer sex practiced among
people living with HIV/AIDS and people at high risk for
contracting the virus.
Studies among traditional high-risk groups suggest the
availability of treatment may be reducing perceptions of risk.
In the US, while many people living with HIV/AIDS are reaping
the lifesaving benefits of improved treatment, prevention
efforts remain inadequate and should be stepped up. Prevention
and treatment must be strengthened together, in balance. A
one-sided focus on either component reduces the efficacy of
the overall program and hampers health authorities' capacity
to control the pandemic.
Treatment Programs Create Political Leverage
Health experts have noted that treatment for current
victims of a disease is easier to "sell" politically
than prevention programs whose beneficiaries are not
identifiable men, women, and children but rather an abstract,
faceless statistical population. "Politicians would
usually prefer to point to living individuals whose lives they
can claim to have saved, than to point to a line on a graph
representing future deaths averted because of their support
for prevention." This may be because those who benefit
from prevention "cannot be sure that they in fact
benefitted as individuals and are therefore less likely to be
grateful (and to show their gratitude at the ballot
We should hear the warning that emotional appeals may
introduce confusion into rational debates on AIDS control.
However, supporters of strengthened prevention efforts are
mistaken to view the political appeal of AIDS treatment as
necessarily harmful to the cause of effective HIV prevention
work. On the contrary, the rising political force of AIDS
treatment activism is the best hope for mobilizing greater
worldwide support for all aspects of the AIDS struggle,
These debates would not be happening at all -- and they
would not be generating the current level of international
attention and concern -- if it were not for the emotional and
moral intensity of campaigns led by treatment activists.
Through the pathos of individual faces and stories, a decisive
human truth emerges: the lives of people with HIV/AIDS matter.
When policymakers and ordinary people respond to this truth
and allow it to influence their decision-making, it is a sign
that political and economic rationality can be informed by
solidarity and compassion.
The demand for treatment creates a degree of political
leverage that prevention alone is unlikely to generate.
By forming a strategic alliance with the treatment community,
HIV prevention advocates can add moral and political force to
the analytic strength of their call for dramatically increased
international investment in prevention. Just as prevention and
treatment reinforce each other in AIDS control efforts, so
they should join forces in the political arena to demand
increased resources for balanced, multisectoral AIDS control
HIV/AIDS and Health Care in an Unequal World
At the dawn of the ARV era, observers like Dr. Jonathan
Mann had discerned an evolving economic caste system within
the global AIDS struggle. The 1996 Vancouver AIDS conference
at which HAART was introduced bore the title "One World,
One Hope." Mann noted the title's unintended irony:
"Today, there is not 'one world' against AIDS, and this
reality of separatism ... threatens progress against AIDS and
is the central reason why real leadership and coherent global
action against [the pandemic] have become virtually
impossible." Unfortunately, Mann's concern with
"separatism" has lost little of its relevance in the
years since he issued his warning.
Fundamental considerations of equity demand that we
organize to transform a system that assigns people with
identical clinical conditions to life or death, based only on
their ability or inability to pay. Of course, the
determination of health outcomes by economic status is in no
way unique to HIV/AIDS. Yet this fact increases, rather than
reduces, the importance of confronting egregious injustices in
the availability of AIDS treatment. AIDS crystallizes the
biological and structural violence of a whole global system in
which poverty kills by direct and indirect means. But breaking
this cycle for AIDS would be a powerful step toward justice in
health care and the sign of a renewed determination to foster
solidarity in a deeply divided world. Thanks to the work of
treatment activists, AIDS focuses public attention and
concern; other deadly diseases that disproportionately affect
poor people have not created similar constituencies. The
charged character of HIV/AIDS debates should be used
politically to maximum effect. AIDS can become the "wedge
issue" that enables a new level of awareness, debate, and
action to attack the full range of global health inequalities.
Excerpted from Alexander Irwin, Joyce Millen and Dorothy
Fallows, Global AIDS: Myths and Facts, South End Press,
Cambridge, MA, 2003. To order Global AIDS: Myths and Facts,
please email email@example.com.
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- More expensive and
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- Creese et al.,
- Ibid. Calculate $1100 per
life-year gained for pilot ARV treatment programs in
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treatment program in South Africa.
- See Creese et al.,
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