World AIDS Day

Sadly, it’s been a long time since I blogged about anything other than travels and adventures. Today, though, it’s definitely time to take a moment to share a few thoughts on something that I’ve been curious about for a long, long time.

When I started graduate school, I chose Social Policy and Development for a few reasons: I knew that discussions of the developing world — Africa, specifically — incited my interest. I also knew that health and education were two arenas that I found most critical. My time at LSE certainly changed my perspectives on many things and brought a number of other issues (refugee resettlement, foreign aid, gender based violence, conflict, etc.) to the fore. Nevertheless, HIV/AIDS was something that was a constant interest for me throughout my time there. At every opportunity, I chose to deliver the seminar that was related to HIV/AIDS, whether it was from a child rights perspective or a health economics perspective. The epidemic is, of course, vastly different in the developing world than it is in the developed world.

The issues that practitioners and policy makers deal with in the US are inherently different than those dealt with by Zambian or South African leaders. While I recognize that HIV/AIDS is still a somewhat silent issue in the United States, I think that education and awareness have increased remarkably and that services have made significant progress, though I am well aware that there is still progress to be made.

In Africa, where a number of countries are faced with populations with rates of infection that are over 10% (Lesotho’s rate is around 23% and Swaziland is around 25%), the epidemic is different. 90% of the children that live with HIV/AIDS reside in Africa. 90%. Many of the children are born with the virus and a number contract it through breastfeeding, etc. I remember learning about Nevirapine in graduate school and being in awe — a single dose is given to infected mothers prior to delivery and the chance of transmitting the disease to the child is reduced by 50%. Why wasn’t this available for everyone?! Of course, there is the issue of money. Drugs cost money and even when they’re subsidized it can be a struggle. Then, of course, the issue of logistics. Provided the infrastructure was awesome and everyone lived in a location that had great access, the drugs could be distributed at a reasonably high rate. Unfortunately, that’s not the case in many areas — people live in areas that aren’t easily accessible and being able to distribute and administer the medication takes man power and a population that’s educated on administering the drug. Further, there’s the ‘issue’ (I use that term loosely here) of culture. While the thought of not using a drug that’s been verifiably effective seems bizarre, culture plays a huge part in the way things are perceived by a given population. Where traditional healers are a big part of society, it would most certainly be more effective educate healers on the matter and give them an opportunity to pass the message along to a receptive community. Even where solutions are perhaps clear, there is always the issue of finite resources (financial and human) and political will.

Beyond mother-to-child transmission, there’s the general issue of transmission amongst adult populations (between 15 – 49). A lot of research that I have come across does note a bit of optimism in the younger generation, probably due to greater awareness and education in recent times. Generally speaking, we have a greater understanding of how HIV is transmitted, the co-factors involved and the ways in which we can reduce the rates of transmission. In terms of behavior, we know, for example, that condoms play a big role and that having concurrent sexual partners also increases the chance of transmission. We also know that women are more likely to be infected and that male circumcision helps reduce the chances of infection. Having that kind of knowledge certainly helps greatly with prevention efforts and guiding people in the right direction.

Of course anti-retrovirals are amazing — many people have lived a number of years with HIV due to the availability of anti-retroviral therapy. [Watch a video of the 'Lazarus Effect' to see the effects of ARVs.] Still, I see a few problems with ARVs (though I was a huge proponent prior to grad school):

1) They’re expensive. The cost is prohibitive, making it very difficult for many individuals to access life-saving drugs. We have seen some amazing public-private and CSR initiatives (like that of Anglo-American in South Africa) where the private sector is stepping up to help in providing therapies for their employees. Still, it is not the responsibility of businesses to provide that and I don’t think it’s reasonable to expect those provisions from companies broadly (though I applaud companies that have stepped up and taken on that role). I could honestly talk on this topic forever. In fact, I did in my dissertation so I’m not going to regurgitate it all through my blog. Suffice it to say, I have mixed feelings about this route.

2) Now, this is a general observation/concern and I, admittedly, don’t have an article to back this up though I imagine there is a wealth of research that exists. If you watch the video of the ‘Lazarus Effect’ you’ll see the physical improvement that is apparent. People go from emaciated HIV victims to healthy-looking individuals that seemingly beat HIV. Well, sadly you don’t ‘beat HIV’, really. You’re still infected, regardless of how healthy you look. As such, you can still pass along the virus to others; others who may not, at first glance, realize that you’re infected. I’m going to preface this by saying that this sounds awful, but it’s just a point to recognize: before ARVs, if you contracted HIV/AIDS and the effects started manifesting themselves physically (the individual is obviously sick at first glance) there was no real way of going back… after AIDS actually set in, there was a short period of time that an individual would be able to live with it. Realistically, during that period, the chances of an infected individual actually passing along HIV was likely minimal — not only is the person pretty weak at that point, but it would be apparent that the individual was infected so the chances of sexual transmission were likely pretty low. Now, however, an individual can be infected for a very long period of time (tens of years even) and not look ill. That provides many, many more years that an infected individual can actually pass HIV along with no real physical signs of the infection for those that are unaware. I’m not saying that people shouldn’t live with HIV by any means — I think that ARVs have been incredible, especially where children are concerned — but I also think that education is a very important component to be tied to the delivery of these drugs. Ultimately, I see ARVs as a great drug, but not a sustainable response.

Ultimately, it comes down to education. I think prevention is the only real answer. Prevention really is key to ensure that mothers do what they can to prevent mother-to-child transmission, that adults are taking every precaution to reduce the chance of spreading infection and that individuals know their options. If children are raised with a great understanding and realize that it’s not taboo to discuss, I think there’s a solid chance that HIV/AIDS incidence will decrease in our lifetime. Here’s to hoping.

Spread the word — #WorldAIDSDay.

A few good reads:

Bongaarts, J. (1996) Global Trends in AIDS Mortality, Population and Development Review, 22 (1)

Caldwell, J. and Pat Caldwell (1993) The Nature and Limits of the sub-Saharan Africa AIDS Epidemic: Evidence from Geographic and Other Patterns, Population and Development Review, 19 (4), pp. 817-848