A day of mixed feelings

I do feel obligated to do a post for World AIDS Day. I laid out some of the basics about the global HIV epidemic while I was in Mexico City for the IAS conference in August. It's obvious that while almost everyone in the rich countries who needs them has access to antiretroviral drugs, there is a major injustice in that 2/3 of the people in poor countries who should be getting these drugs are not, and we're falling further behind every day, as more people become infected. Actually, based on the latest indications for treatment, the gap is even bigger than that, more like 3/4 who are not being treated who should be. The cost of first-line regimens in the poor countries -- due to agreements wrested from the pharmaceutical companies with great difficulty -- is $95/year per person, which means it would cost about a billion dollars a year to buy the meds for people who currently aren't getting them.

It would cost a good deal more than that to actually deliver them to places that currently lack basic health care infrastructure, and many people argue that "HIV exceptionalism" -- placing HIV ahead of other important public health problems -- is distorting spending on global health and making it less cost-effective. It costs much less, for example, to provide people with insecticide-treated bed nets to prevent malaria -- just a couple of bucks -- and the payoff is at least as great. But that's a false comparison, because what matters isn't an abstract cost-effectiveness analysis of existing spending, what matters is what is politically possible. There is vastly more than enough money available to do both, and a lot more than both, if we had the political will.

The powerful movement and infrastructure to combat HIV and AIDS in the poor countries is of immeasurable strategic value. This infrastructure exists in large part because people living with or affected by HIV in the U.S. and Europe, after campaigning for universal treatment, prevention programs, and client care services in their own countries realized that it would be hypocritical of them not to work just as hard on behalf of people less fortunately situated, particularly in Africa. Rather than get into a squabble with this movement over the allocation of resources, advocates for broader public health measures need to support it in exchange for leverage.

Building public health and health care infrastructure in poor and remote places will do a lot more than facilitate the delivery of ARVs. The same distribution routes and workforce that dispense ARVs can provide immunization, health education including not only HIV prevention but practices to provide safe drinking water and otherwise promote community health, midwifery services, and the other basics. These programs can employ women and combat gender, ethnic and caste discrimination. We can build on HIV care to find and treat tuberculosis and parasitic diseases.

So, my mixed feelings are whether we should have a World AIDS Day and not just a World Health Equity Day. But I'm willing to take the situation where I find it. Let's build on the movement to combat HIV and AIDS, eliminate associated stigma and discrimination, and elevate the principles of justice in HIV prevention and treatment, and extend those values and that energy to global justice in every realm.