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The global AIDS crisis

Dennis AltmanDennis Altman
d.altman@latrobe.edu.au

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Matt Smith:

Welcome to the La Trobe University podcast. I will be your host, Matt Smith. I'm here today with Professor, Dennis Altman from the La Trobe University Politics Program and Director of the Institute for Human Security. Thank you for joining me, Dennis.

Professor Dennis Altman:

Hi, Matt.

Matt Smith:

We're here today to talk about an aspect of the Millennium Development Goals which is – would it be fair to say, it's a lofty aim – to have halted by 2015 the spread of AIDS and HIV. Well it's also got the word 'reverse' in there, to reverse the spread.

Professor Dennis Altman:

At the moment, for every person who gets put on treatments, there are probably at least two people who get infected. So you know, the time we're going to sit and talk, there will be a number of people going on treatment. I can't give you an exact figure.

At least twice that many people, probably more, will be infected with HIV. Most of those people won't know they're infected with HIV. Most of them, if they are in poor countries or indeed in bits of some rich countries like the United States, won't discover that they are positive for a long time and probably only when they start showing symptoms of debilitating illness.

So yes, I think you're absolutely right, the idea that the spread can be reversed in the next five years seem to be very unlikely. Certainly, there have been some major steps and the number of people who are now accessing treatments is a lot more than when the Millennium Development Goals were first promulgated but it's nowhere near, nor do I think it will be, anything like the universal access that the goals talk of.

Matt Smith:

It's got a problem that most of the goals seem to have, which is the problem areas for HIV and AIDS is in developing nations, specifically in Africa, which find it harder to help themselves and to attain these goals. Even when the goals were set, was it realistic to say that they could be reversed when it's a disease that can't be cured.

Professor Dennis Altman:

Of course, this is one of the big arguments, I suppose, almost a philosophical argument about the Millennium Development Goals. Is it useful to set targets that we probably can't reach? On the other hand, they do set a yardstick that you can hold governments to account over and say, "Well, why are you not at least doing everything possible to reach those?"

And you're right. The bulk of the epidemic is in Africa, although not necessarily one of the fastest growing epidemics. There they're quite different. I mean, in terms of sheer numbers of people infected, yes, it's in Sub-Saharan Africa and there's huge varieties. So there have been parts of Sub-Saharan Africa where the epidemic does appear to be reversing. There are other parts of Sub-Saharan Africa where it is clearly growing. But the worst growth in terms of sheer numbers of new infections or percentages of new infections is probably now in parts of the former Soviet Union, in Central Asia, and in countries much closer to us like Papua New Guinea.

So that one has to answer the question in very geographically specific terms. I think it is possible in a country like Papua New Guinea, which has a major epidemic but certainly not one on the scale of South Africa or Botswana, it would actually be quite possible to reverse the trend of infections. For that to happen though, would require a certain amount of political will by the Papua New Guinea government that, by and large, just doesn't appear to be there.

Matt Smith:

Well, not just that. A good deal of humanitarian work, I imagine, as well.

Professor Dennis Altman:

Well, there are two goals you got to distinguish. One is getting people who are already infected on to treatment. Now, that involves a certain level of resources, obviously. You got to be able to afford the drugs. But more importantly often, you got to be able to have some sort of health infrastructure to get people monitored. Put them on the drugs and then watch the drugs are affecting them, because these are pretty strong drugs that have nasty side effects. There is a quite horrific story that is always a warning, which is in Mozambique, which has a major epidemic, 100,000 people were put on treatments in one year. That sounds very impressive except at the end of the year, 40,000 of them had vanished. No one knew where they were. There wasn't follow-up possible.

You're talking about poor countries, you're quite right, poor countries where the health infrastructure doesn't exist. Now when you come into prevention, it's quite different, because prevention doesn't necessarily demand a huge amount of resources. What it demands is a lot of honesty and a willingness to talk openly about behaviours that most governments are very uncomfortable with, namely, sex and shooting up with needles.

And when you go to a country like Papua New Guinea, going back to our neighbourhood, you have people who are doing extraordinarily good work in trying to explain to people what the dangers of unprotected sex are. At the same time, you have quite crazy evangelical clergy in Papua New Guinea who are telling people that AIDS is God's wrath and if you have sex, this is your punishment. And it's getting through that that is the real problem. It's not so much about resources but political will.

Matt Smith:

Is that sort of thing going to be reversed easily? Is it a Millennium Development Goal that is being given sufficient attention?

Professor Dennis Altman:

It is given a huge amount of attention for the first, I guess we could now say, first decade of the century seeing we're now in the second decade, for a couple of reasons. One of which was a lot of very effective mobilizations and advocacy by AIDS organizations, particularly in some of the poor countries like South Africa and Brazil. And Brazil actually is a great model of what to do right. South Africa is a model of what to do wrong, until recently.

But the other thing which a lot of people find a bit disconcerting when it's pointed out to them is the leadership of President George W. Bush. This is one of the few areas where I would actually say for all the things that the Americans were pushing that I'm uncomfortable with around prevention, in terms of getting people onto treatments, The Bush administration actually did make a huge difference in a number of parts in the world. And for a period, there did seem to be an international commitment to this goal, which also includes dealing with tuberculosis and malaria. So the global fund to combat AIDS, tuberculosis and malaria was established. A lot of money went into that fund, primarily, American money both public and private from people like the Gates Foundation.

As we enter the second decade, I think there's a declining willingness to put those resources in partly because it's getting more and more expensive. The problem with HIV treatment is that it's not a one-off shot, it's not like you put someone in a course of antibiotics and that's it. You actually have to put people on drugs for life, and you have to monitor them. That's a very expensive undertaking. Of course, it gets more expensive the more people you put on treatments. And there is not an open-ended checkbook. And the Obama administration is showing signs of being less supportive of that approach. Possibly more supportive than the Bush administration were of sensible prevention methods. But that, I think, still remains to be seen.

Matt Smith:

There's also a, when I say it, it's going to sound easier than it actually is, the option of trying to find a cure and approaching it from that method.

Professor Dennis Altman:

Since the beginning of the epidemic, there has of course, been a search constantly for the magic bullet. And the magic bullet isn't so much a cure as a vaccine. And back in 1985 which is 25 years ago, a quarter of a century ago, Ronald Reagan's Secretary of Health got up and said, "We will have a vaccine in the next couple of years." It was a very silly promise and of course, we don't have a vaccine and the evidence is that we're not very close to a vaccine.

And I'm not a scientist. You can talk to people. There are actually people in La Trobe who understand this and I don't. But I do understand that the possibilities are not good at the moment in the short-run. A cure is probably equally unlikely although if you have sufficient medical resources, you certainly can keep people alive and in reasonably good health. But to do that requires, as I said, constant monitoring and it requires complicated drug regimes. And of course, the great fear is that the virus itself could mutate. Now, it cold mutate and become less damaging. But in people that are already infected, the chances are that the treatments they're on will be less effective. They need new treatments.

Go back to the Mozambique story of almost half of the people you initially put on treatments don't come back for reasons quite often beyond their control because they're caught up in extreme poverty, there's no medical centre to go to, there just aren't enough trained physicians and nurses. Then the idea of keeping people properly treated is I think, pretty unlikely.

What it comes back to is with our current knowledge, it would make sense to put emphasis on major prevention. But that is very difficult for a large number of countries because of a large number of religious and cultural prohibitions against acknowledging that people do all sorts of things that their leaders would prefer they didn't do.

Matt Smith:

This is something that extends to all Millennium Development Goals, really, especially this one with it being a Third World problem. Are developed nations and First World nations picking up the slack for Third World nations with this and other Millennium Development Goals to the extent that they should be, because a lot of the responsibility rides on developed nation's shoulders to be very generous and to be very supportive to try and help other nations catch up?

Professor Dennis Altman:

You know, I think it's more complicated than that. Firstly, there are some developed countries, the United States is a great example in which HIV is still spreading quite rapidly. And the United States has a major HIV epidemic. United States has been unwilling to do what most other Western countries, including Australia, have been willing to do. Particularly in the case of the US, an unwillingness to adopt needle exchange as a sort of universal national program which Australia did earlier on and which meant Australia has had remarkably little infection through needle use, even though Australia international terms is a country in which people shoot up an awful lot. There are parts of Melbourne you could go to see that I'm right. There are some very rich countries, Japan for example, small epidemic but it's rapidly increasing, again, because there's great denial in Japan. In Japan, the epidemic is spreading primarily among young homosexual men, and the Japanese government is not putting resources into that and has little awareness.

Having said that – I mean the other thing I want to say is there are some quote developing countries whose programs are actually far ahead than those of many rich countries. I mentioned Brazil already. Thailand with some ups and down, but Thailand has certainly had a very serious commitment by its government now for 20 years. Botswana with a huge amount of international help, certainly has put a huge amount of resources into the epidemic.

In the end, though of course, what you're talking about, you're absolutely right. What the Millennium Development Goals are really saying when you put them all together is saying, "We need an equitable and better distribution of resources in the world."

The total amount that is spent on treating people with life-threatening diseases, I don't have the figures at hand, is probably less than the amount that people in rich countries spent to celebrate one day on the 25th of December last year. And of course, the irony is if you put to most people, "How about you have an ordinary dinner and you don't have presents. And this would save thousands of lives." Most people, I suspect, would say, "That's not a bad idea."

The problem is our political systems don't work that way. They lead to the source of politics where somebody like Barnaby Joyce comes up and says, "Combating global warming is really about giving to Robert Mugabe." And in that environment of short-term political gain, getting that redistribution of resources is difficult.

Matt Smith:

Well, maybe not holding a big fireworks display on New Years' Eve.

Professor Dennis Altman:

Indeed. You try and sell that to the premier of New South Wales who obviously saw the fireworks as the last chance to keep her job.

Matt Smith:

You pointed to Japan and America as having an increasing AIDS rate. At least, they're properly resourced, that if they wanted to make a change, if they wanted to seriously commit to it, they could.

Professor Dennis Altman:

They could, yeah.

Matt Smith:

They've got the resources to do that.

Professor Dennis Altman:

I mean going back to what I said about South Africa and oddly enough, President Zuma has actually started to improve enormously South Africa's response to AIDS. Under Mandela and under Mbeki, the government was appallingly negligent. And the argument you made about fireworks, which I agree with,, you could equally say, "Well, South Africa did not need to buy submarines when thousands of South Africans were dying of AIDS." And I think one has to be careful. I mean, of course, there needs to be redistribution, but it is equally true to say that in the end, governments have to look after the security of their citizens. That is their primary obligation. And there are many parts of the world where huge expenditure on military weapons and military inventions, could far be better devoted to domestic health and education. South Asia is a classic case. I mean, the Indian government has actually over the last few years been doing much more on HIV. But India has a large AIDS epidemic. It's hard to argue that India needs foreign assistance to deal with it. If the Indian government actually took it seriously enough, they have the domestic resources.

And I think we have to find the balance. I don't think we have to keep feeling guilty, and I think it's bad to make us in the West keep feeling guilty because we are rich and don't share. The Saudis are richer and they don't share either except when it is exporting fundamentalist Islam. I think there is a sense in which it is too easy to blame us when we are often the only people who are willing to support programs that work.

Matt Smith:

In regards to the conference that was held at La Trobe University recently, did any good think-tank results come out in regards to the treatment of AIDS and HIV?

Professor Dennis Altman:

No, and I wouldn't expect it to. I think that what I would have hoped is that there was more integration of the discussions around HIV/AIDS, and the development more generally. I mean the problem is that there is a large and important AIDS movement but it tends to not have much to do with a broader development movement. And equally in the development world, there is a certain amount of strange ignorance about AIDS, even though most of the big development agencies have programs relating to HIV. I think it is getting those discussions that I'm interested in.

The big international AIDS conferences attracts up to 25,000 people. So we're obviously not in that league, nor are we trying to. The real issue around HIV/AIDS is not getting more medical discoveries. It is actually doing some common-sense prevention where the problems are not about biomedical knowledge. They are about political and cultural obstacles, and getting a discussion around that seems to me the top priority.

Matt Smith:

Professor Dennis Altman, thank you for your time today.

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