Map of life expectancy at birth from Global Education Project.

Monday, August 21, 2006

Exploiting Exceptionalism

No dramatic news came out of the recently concluded International AIDS Society meeting in Toronto, but the undramatic good news is that the situation does not appear as grim as it did a few years ago. The number of HIV-infected people worldwide continues to grow, but not at the explosive rate we once feared it might. Prevention efforts in the wealthy nations have kept prevalence rates fairly steady, and in most of the poorer nations, they have begun to have a noticeable impact. The insistence of the United States government that a large share of its contribution to the global campaign against HIV be devoted to abstinence only programs means that local public health workers cannot use the money as effectively as they could, and the U.S. is still far short of fully funding its commitments. But at least we're doing something.

In the current NEJM, Jim Yong Kim and Paul Farmer review the current state of the global epidemic. They particularly emphasize antiretroviral treatment, which has now become available to far more people in Africa and other poor countries thanks to inexpensive generic versions of the drugs manufactured in China, India and Brazil. They call for expanding access to all HIV related drugs to everyone who needs them.

This emphasis may at first seem to miss the mark. These drugs are not a cure, they often have serious side effects, and while they extend life expectancy for an average of 13 years compared with no treatment, people living with HIV can still expect to get sick and die of effects of the disease eventually. Some people even fear that the availability of treatment may make some people think that acquiring HIV infection is not such a terrible thing after all and so undermine prevention efforts. Furthermore, why should we extend HIV care to everyone while not providing all of the other basic needs? I have written before about the Millenium Development Goals, which are not being met: the 11 million children under five who die avoidably every year, not from HIV but from contaminated water, malnutrition, malaria and other diseases; the half million women who die every year in childbirth; and many other terrible problems.

But the willingness of the wealthy countries to invest in HIV care, although it seems an unjustifiable exception, represents an opportunity as far as Kim and Farmer are concerned. Succeeding with antiretroviral treatment requires building or rebuilding adequate health care systems in the poor countries, stopping the brain drain of physicians and other health professionals, and meeting basic needs for transportation, nutrition, etc. If we do those things, we will have the basis for fighting all of the fundamental threats to life and well being in the poor countries. So why not ride HIV exceptionalism as far as it will take us, toward meeting all of the essential goals?

But Kim and Farmer also point to a grim development, the spread of highly drug resistant pathogens -- HIV, TB and malaria in particular -- which are feeding on the HIV epidemic but threaten all humanity. In the same issue of the journal there is an article on the growing prevalence of antibiotic resistant staph infections in the United States. And we also have growing problems with C. difficile and other nasty drug resistant bacteria.

This is happening, of course, because of that non-existent, satanically inspired mythical phenomenon of evolution. Even as we build up our capacity to battle our ancient enemies throughout the world, they are developing their own capacity to defeat our weapons. It is impossible to overstate the urgency of this matter. We'll continue to follow it here.

BTW: If you haven't already noticed, you need to hit the "refresh" button on your browser or you're likely to be seeing a two- or three-day-old version of this (or any) blog. I update faithfully every day except Saturday.


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