Deadly failure of nerve Font Size: Decrease Increase Print Page: Print Medical advances in treating
HIV are helping many but only better prevention policies can save millions more from infection,
writes Bill Bowtell | July 28, 2007
THE HIV pandemic need never have happened.

There is nothing inherent in the human immunodeficiency virus that made 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 main driver of HIV, which causes AIDS,
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 across
the world. They ranged from executions of HIV-positive people, repressive sanctions, quarantine and
denial to mass education and practical and evidence-based policies based on prevention.

Many governments were, and remain, reluctant to offend social, cultural and religious beliefs about
sexual behaviour, drug consumption and sex work, especially among the young. Nevertheless, by the end
of the '80s it was possible to judge these responses and determine which had worked best to lower new
infection rates to sustainable 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 '80s, all the information and evidence
about HIV-AIDS that was needed to bring the incipient global pandemic under control and implement
long-term management was available.

The feasibility of preventing its spread had been demonstrated in Australia and The Netherlands and
in large developing countries such as 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 during a decade from 1985 in which decisive preventive action
almost certainly could 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, experts pushed for leading countries and 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 shameful and enraging.

In the 20th 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.

Those who naively declared war on HIV-AIDS in the '80s 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 declared by the US in the '70s. 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 minimise
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 US 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 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.

For more than two decades, the UN and its specialised agencies have been a 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. Throughout the '90s, the US, the Vatican and its ideological allies
pursued their wars on drugs and sex through the UN.

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. Through 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.

In the past 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 conventional wisdom has emerged within
some elements of the medical and scientific community that discounts prevention as achievable or
practical. This school of thought has been greatly influenced by the development of effective
anti-retroviral treatments.

During these 10 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 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 mean people
have an incentive to be tested. 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. Yet this apparently more benign framework created a dangerous set of perverse
incentives that distort the global management of the pandemic.

Most of the billions of extra dollars devoted to HIV-AIDS in the past decade have been absorbed by
drug companies, doctors and the medical system for care and treatment.

During this decade, the results are 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 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 may 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
developing and developed worlds. The present global caseload is 40 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 size of which is transforming the nature of the threat, with immense new costs on
national economies and the international system. The costs of providing anti-retroviral therapies to
a significant proportion of a global caseload that may number 80 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 $US1000 ($1130) a person a 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 HIV will increase its resistance to drug
therapies and facilitate the spread of new strains of dangerous pathogens, especially highly
drug-resistant tuberculosis.

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, shopping centres, 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 editorialising about virtue and social improvement.

What is 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 every bit as attractive as those that
already exist in the system to create care, treatment and research. 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.

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.

This is an edited extract from "Applying the Paradox of Prevention: Eradicate HIV", in the spring
2007 edition of Griffith Review, which will be launched at the Byron Bay Writers Festival today. Bill
Bowtell is director of the HIV-AIDS project at the Lowy Institute for International Policy. As senior
adviser to the Australian health minister from 1983 to 1987, he was an architect of Australia's
response to HIV-AIDS and was national president of the Australian Federation of AIDS Organisations.
He recently completed a Lowy Institute policy brief, HIV-AIDS: The Looming Asia Pacific Pandemic.
This week Sydney hosted a big HIV-AIDS international conference.

www.griffith.edu.au/griffithreview