All humans can contract AIDS

dennis-altman Professor Dennis Altman

Professor Altman will be speaking at the Millenium Development Goals conference at La Trobe University on 30 November and 1 December.

First published in the Canberra Times, 28 November 2009

On a balmy August night this year the President of Indonesia, opened the largest regional AIDS Conference yet held in Asia. In his speech, little reported in the Australian media, Susilo Bambang Yudhoyono welcomed the partnership and bravery of “positive women; people living with HIV; survivors of injecting drug use; sex workers; and the network of gay, trans-genders and men who have sex with men.”

Remember that at the large General Assembly debates on AIDS in 2001 and 2006 the very acknowledgement of those most vulnerable to HIV, and certainly the use of terms such as sex work, gay and trans-gender, was one of the most controversial issues, with Islamic states, the Catholic Church and the Bush Administration all opposed to the naming of these groups. AIDS remains a disease marked by enormous stigma, which in turn means both prevention and treatment efforts are constantly stymied by moralisms triumphing over realism.

The popular image of the epidemic counterposes a controlled and small epidemic, largely confined to homosexual men and needle users, in rich countries with a much larger one, usually identified with women and children, in poor countries. Overall this is not inaccurate, and the sheer number of infections in sub-Saharan Africa means they account for perhaps 70% of all HIV cases in the world. In countries such as South Africa, Botswana and Zambia one in four young adults in many communities will be positive, and this is reflected in death rates and large numbers of orphans.

But the realities are somewhat more complex. The fastest rising epidemics include those amongst drug users in the former USSR and homosexual men in southeast and east Asia. In both cases these are populations who have been stigmatized by governments and ignored in prevention programs. Reluctance to talk honestly about human behaviour has meant real distortions in messages, which are often directed at low risk but politically safe targets such as “youth”.

It is true that outside sub-Saharan Africa, AIDS has not turned out to be the massive pandemic predicted in the 1990s. In our part of the world there are significant increases in Papua, both East and West, and amongst particular populations, especially injecting drug users and men who have sex with men. In absolute numbers India, and perhaps China, have potentially major epidemics. UNAIDS reports of China that: “The number of people who have a high risk of exposure to HIV could be 30-50 million: mainly injecting drug users and their sexual partners, sex workers, their clients and partners as well as men who have unprotected sex with men. However there are currently no signs of a generalized epidemic in the country. The Government aims to keep HIV estimates below 1.5 million in 2010”.

Globally HIV infections are rising two to three times faster than the numbers of people who can access treatments, and this is true even in middle income countries with good access to antiretroviral drugs, such as Thailand. AIDS is both a product and a cause of global links. Its spread grows out of existing inequalities and injustice: apartheid in South Africa; civil conflict and collapse of the state in Rwanda and Kenya; poor governance in Zimbabwe. In some countries HIV/AIDS is clearly a further burden on already overstretched social, economic and political structures. At the same time it is the major cause of premature death in increasing numbers of countries, striking most at infants born to HIV-positive mothers and at young adults in the most productive years of their lives. A whole generation of AIDS orphans is now developing across many parts of the poor world, children growing up in societies in which only the children and the old people remain.

The epidemic reverses development: it involves the loss of skilled labor, a decline of industrial and food production; the collapse of family structures and greater stress on social and health services. Its direct political impact is less obvious, although in some African countries there appears to be evidence of a “hollowing out” of institutions, as governing elites become sick and die. There is also a psychocultural impact: mass deaths and illness will trigger a set of irrational responses, such as anger, denial and scapegoating. Because such impacts are hard to measure, and are politically sensitive, there has been a reluctance by most of those who work on the epidemic to really explore the ways in which AIDS reshapes those who are most affected, although there is a rich store of personal, literary and cinematic responses to the epidemic that are too often ignored by social scientists in their search for ‘scientific data’.  
Currently global attention to HIV is far less than it was in the beginning of the century. Both more conventional threats, especially those associated with nuclear proliferation and terrorism, and the twin spectres of financial crisis and climate change have taken centre stage. This does not mean that the threat of HIV is less urgent, indeed the decline of attention may make it all the more significant.

It is the nature of non-traditional threats to security that they tend to compound each other. Climate change is closely linked to problems of food and water security, which in turn will increase vulnerability to a number of diseases. This is less obvious in relation to HIV than to water borne infections and malaria, but any increase in impoverishment will make it more difficult to maintain antiretroviral therapies. There is already some ongoing research, supported by UNAIDS and UNEP, which is examining the connections between the two crises, although the connections seem at this stage to be indirect.
The greater threats may well come from the interaction of traditional security threats, especially when they lead to massive dislocations of people as is now happening in parts of Pakistan and Afghanistan. So far research on HIV in Pakistan has pointed to small rates of infection amongst the groups usually regarded as most vulnerable in Asia, and called for further outreach to marginalised communities. But the massive dislocations now occurring because of civil conflict, the increasing disruption to traditional communities and ways of life, all create the conditions for more commercial sex and drug use among people who are most unlikely to feel any kinship with identity based organisations.

The combination of political instability, climate change, food and water shortages and increasing and uncontrolled movements of people all mitigate against effective HIV prevention and treatment. None in themselves are causes of the spread of the epidemic, yet the ways in which they decrease attention to HIV prevention and care in themselves increase the chances of the epidemic continuing to grow

The move to conceptualise HIV as a security issue dates back to the early 1990s, and was born of a political desire to place it higher on the political agenda as much as through an analysis of its impact on global stability. There is evidence that officers in the CIA had been urging their superiors to consider the impact of HIV/AIDS on national and international stability since the late 1980s. This view was expressed in several high level reports such as that complied jointly by the Chemical and Biological Arms Control Institute and the Center for Strategic and International Studies in the United States which claimed to “directly link health and global security for the first time”. The report stressed the rapidity with which infections can spread; the threat of biological weapons; and the consequences for health of regional conflicts and failing states.

The linkages between HIV and security was taken up publicly by the United States at the end of the Clinton Presidency, when the issue was placed on the agenda of the Security Council, largely due to American pressure, influenced particularly by Vice President Al Gore and Ambassador Richard Holbroke. In their resolution the Security Council stressed that the pandemic, “if unchecked, may pose a risk to stability and security,” and referred to the ways in which “conditions of violence and instability” increased the risk of exposure to HIV. The following year the General Assembly devoted a special session to the issues of HIV/AIDS and spoke, rather, of the epidemic, especially in Africa, as “a state of emergency which threatens development, social cohesion, political stability, food security and life expectancy, and imposes a devastating economic burden”.

The sense of HIV as a major security issue underlay some of the rhetoric that surrounded the Bush Administration’s massive commitment of funds to HIV treatments and, on a lesser scale, prevention. [The extent to which the prevention programs were influenced by a certain moralism, that placed emphasis on monogamy and abstinences, is one of the best known aspects of PEPFAR, the President’s Emergency Fund for AIDS Relief]  To some of its critics PEPFAR was just another example of American determination to exercise global domination. I think this view underestimates the extent to which altruism was a major factor in contributing to U.S. policy making, and indeed AIDS might be seen as almost paradigmatic case of the American desire to “do good”. Despite its imperfection—the emphasis on abstinence education; the hostility to working with sex workers; the support for US produced pharmaceuticals—PEPFAR has undoubtedly saved lives. One study from Stanford suggests that Pepfar has averted 1.2 million deaths, and in its first four years (2003-07) cut the H.I.V.-AIDS death toll by 10.5 percent in targeted countries.

A failure to continue its funding, which is possible if the United States makes major budget cuts in coming years, will be tragic. The most recent G8 Conference failed unlike its predecessors to make any specific commitments to meeting the target of universal access to treatments for HIV by next year, one of the specific pledges in the Millenium Development Goals.

The other part of the MDG promise was to “halt and begun to reverse the spread of HIV/AIDS” by 2015, and the fiercest debates now going on within the AIDS world are around the intersections between treatments and prevention. Some medicos are attracted to the idea of ‘treatment as prevention’; that is, if everyone who might be infected is tested and where necessary put on ARVs, the overall infection rate will fall dramatically. The sheer practical difficulties of doing this in many parts of the world make me deeply sceptical of whether it is an effective replacement for the more complex programs of peer education, provision of condoms and clean needles, and attempts to change sexual cultures that underline the successful behavioural interventions that have limited the spread of HIV amongst many groups internationally.

Part of the attraction of the ‘treatment as prevention’ approach is that it hands control to the medicos, and avoids the bitter moral arguments that have bedevilled so many programs directed at groups seen as deviant and immoral. Yet in both rich and poor countries there have been remarkable successes in lowering infection amongst sex workers, homosexual men and drug users where appropriate information and resources are made available.

If one can overcome the prejudices and barriers thrown up in the name of religion, culture and tradition, preventing HIV is not that difficult. The major obstacle comes from fundamentalists who preach against condoms and needle exchange in the name of morality, a key issue in parts of Papua New Guinea.

This is why the honesty in President Yudhoyono’s speech was so significant. It is only when governments, churches and international organisations are able to accept the diversity of human behaviors without imposing ideological strictures upon them that there will be a successful set of global prevention programs able to halt the spread of HIV.