More on AIDS exceptionalism

I've now had a chance to carefully read the original NEJM article by Patrice Severe et al on antiretroviral therapy in Haiti. As I said before, it isn't news that ARVs can be successfully administered in poor countries, but some people had remained skeptical about Haiti, which may present one of the most difficult environments.

But there is a bit of a -- puzzle? dilemma? oddity? Most Haitians live on less than a dollar a day. (That, believe it or not, is the World Bank's official international poverty line.) The program to treat HIV with ARVs, described in the article, costs about $1,600 per person per year. That includes providing food -- rice, beans and oil -- the most undernourished patients, and nutritional supplements to all of them. The participants also were treated for TB and other co-morbid conditions.

Now, think about this. Most Haitians are probably borderline malnourished, and a high percentage of them suffer from clinical malnutrition. But now they can get an adequate food supply -- if and only if they are HIV infected. Most Haitians seldom or never get to see a doctor, even though many of them carry tuberculosis and have other chronic diseases. But they can get comprehensive medical care -- if and only if they are HIV infected.

It is rather odd, and not entirely clear, why there is public demand, and government and philanthropic support, for taking care of people in impoverished countries who are infected with HIV, but no comparable demand for doing anything much about all of the other severe health problems faced by people in these countries. Under the present regime, it might actually make sense for some people to go out and deliberately acquire HIV infection in order to get access to medical care and nutritional benefits.

By the way, there are comparable situations right here in the U.S. -- housing, vocational, mental health and substance abuse treatment programs that are available only to people living with HIV. Some people actually claim falsely to be HIV infected in order to get access to these programs, and the programs have to require proof of HIV infection. But people without HIV are out of luck -- no mental health care for you, pal, you failed to practice unsafe sex or share needles.

Just something to think about.