When thinking about HIV, I often think back to that timeless question. Which came first the chicken or the egg? In the case of HIV, the question becomes which came first HIV or poverty? It’s hard to argue against the fact that impoverished people are often the most at risk for contracting HIV. Lack of education, economic opportunity, and choice put the poor at a distinct disadvantage. Yet as D’Adesky talks about in the Carletonville chapter, HIV also can lead to poverty. Sickness leads to lack of productivity, while the price of treatment can leave families bankrupt. Thus HIV and poverty becomes one vicious circle.
The treatment model assumes that HIV came first (or at least that HIV should be the point of intervention). In doing so, they tend to address the cause and not the root of the problem. This is all too common nowadays. Whether it’s the influence of internet or improved technologies we tend to want the quick fix for things. Its easier to provide treatment than to alleviate poverty. I think this is also part of the reason HIV is spreading so quickly. People want instant gratification, be it sex or drug related, and don’t think of the consequences of their actions. In order to truly change behavior we need a MAJOR shift in our value system. The generations before us saw the benefits of sacrifice and thinking in the long-term, be it by rationing food and gasoline during World War II, or starting a Social Security program to pay now for future benefits. The treatment model applies the same old band-aid approach to HIV.
I really enjoyed reading Alex De Waal’s book AIDS and Power; mostly because he urges people to think outside the box. Clearly our current HIV policies are not working. The numbers of people with HIV keep increasing, yet we keep trying the same education and treatment campaigns.
D’Adesky and De Waal would agree that AIDS efforts are driven through institutional and political efforts, but D’Adesky focuses entirely on the micro issues of drug treatment and pricing where De Waal sees the bigger picture. I really liked De Waal’s idea about creating incentives for governments to act. Rather than rewarding government’s that have failed to take a leadership role in preventing HIV with large amounts of humanitarian aid and filling in where they failed to provide for their people, we should punish them for increased HIV rates. In the short term, the affects would be catastrophic and would lead to many unnecessary deaths, but for (gasp) LONG TERM thinking, this might be the best solution.
Also, I think there is real danger in treating HIV like a chronic disease. People let their guards down and make risky decisions. Stigma may be reduced, but what’s the use of decreased stigma when everyone’s walking around with HIV?
Finally, to answer one of my original goals of this blog about how I would start a book about HIV, I think I would start with a joke. Something that may be offensive, but is still a change from the status quo. Something positive. Something upbeat, and something that doesn’t involve boring figures…
So, I apologize for this one, it’s late….
Why did this book fail to give me insight?
Because it didn’t have enough visual AIDS.
Friday, May 9, 2008
Thursday, May 8, 2008
End of Book....
Usually when I finish a book about HIV I feel inspired, impassioned, and excited to start working in the field. Honestly, when I finished Moving Mountains I just felt tired. D’Adesky even pulled out the big guns at the end, calling the current failure to reach all HIV infected people genocide, and naming the Bush Administration as one of the key culprits. She criticizes Bush (along with big corporations) for politicizing prevention efforts by creating his agenda (namely abstinence, lack of condoms) but also for using economic and trade deals to block generic drugs from reaching the places that need it the most.
On this point I agree with her. Bush has perhaps done much damage than good with his PEPFAR initiative, which has weakened the Global Fund, and created distracting turf wars in funded countries where U.S.-backed NGO’s compete with local government agencies for money as well as program direction. The damaging affects of his presidency will surely be felt for the next generation if not longer.
Bush perhaps says it best:
"Oftentimes people ask me, 'Why is it that you're so focused on helping the hungry and diseased in strange parts of the world?'" --George W. Bush, Washington, D.C., April 18, 2008
Maybe he should stop "helping" these strange people then.
On this point I agree with her. Bush has perhaps done much damage than good with his PEPFAR initiative, which has weakened the Global Fund, and created distracting turf wars in funded countries where U.S.-backed NGO’s compete with local government agencies for money as well as program direction. The damaging affects of his presidency will surely be felt for the next generation if not longer.
Bush perhaps says it best:
"Oftentimes people ask me, 'Why is it that you're so focused on helping the hungry and diseased in strange parts of the world?'" --George W. Bush, Washington, D.C., April 18, 2008
Maybe he should stop "helping" these strange people then.
Treatment Bible
Part III of D'Adesky's book is basically the Bible of for all things treatment related. D'Adesky summarizes the benefits of HIV treatment:
And who can argue against the ethical argument?
However, for the next 50 or so pages D'Adesky highlights the barriers to care...
- Contrary to previous beliefs, treatment can world in developing settings. (look at Brazil, Cuba etc.)
- It allows countries to build up their infrastructures (through additional foreign and humanitarian aid) and can provide models of care for other diseases
- Relieves the suffering of thousands, and is the morally and ethically appropriate thing to do.
And who can argue against the ethical argument?
However, for the next 50 or so pages D'Adesky highlights the barriers to care...
- adverse affects
- multi Drug Resistant-HIV
- costs of second-line therapies
- lack of food, resulting in difficulty swallowing ARV medications
- lack of clean water sources
- adherence issues, namely cost of medications
- superinfection (when an HIV positive person develops a more powerful, resist strain of HIV
- other Opportunistic Infections's (TB, Malaria, etc.) that can interfere with ARV regimens
- difficulties associated with treating children, women, and hard to reach population such as drug users.
- potential development of new not treatable strains of virus
- complicated training and human resource issues (medical literacy, different drug regimens etc.)
- ethical issues associated with research
Wednesday, May 7, 2008
Za Zdorovie!
We shift back to reality in Russia, as D'Adesky depicts a depressing scene on the Russian AIDS front. Having lived and worked at an AIDS center in Kazakhstan, this chapter sounded very familiar....Russia has the fastest growing rates of HIV in the world, which are running rampant in the drug user population and unfortunately making the transition to heterosexual contact.
The government response has been minimal and that seems unlikely to change given the cultural context of the country. The remnants of communism is guiding the much of the HIV response. Under the paternalistic nature of the Soviet regime, citizens were taught to obey, not question authorities. This has led to difficulties cultivating HIV advocacy groups, as stigma is widespread, little regard for individual rights exists (people are often testing unknowingly for HIV when they go for regular checkups (!!)), and ARVs are not affordable to the average Russian.
Harm reductions programs, namely distribution of clean needles to drug users, is the primary response by NGO's yet this has only contributed to increasing stigmatization of these groups.
For me the most interesting, and terrifying, part of this chapter was D'Adesky's description of the treatment of orphans. HIV positive infants who are orphaned (or abandoned) are housed at Children's hospitals. These hospitals, like much of Russia, are understaffed and underfunded. Increasing the problem, is the government's mandate to keep these infants in the hospital until they test negative for HIV. (Oftentimes, newborns carry passive maternal HIV antibodies that are shed within 18 months.) These infants stay in hospitals wards for months and many show signs of delayed development-which is common for institutionalized youth.
Like Tonya Thurman mentioned in her lecture, there is a growing movement away from orphanages and other institutionalized settings. Again, given the cultural context and stigma associated with HIV in Russia it seems unlikely that the government will shift to a model of community-based care. Which come to think of it is rather ironic given the underlying concept of communism.
The government response has been minimal and that seems unlikely to change given the cultural context of the country. The remnants of communism is guiding the much of the HIV response. Under the paternalistic nature of the Soviet regime, citizens were taught to obey, not question authorities. This has led to difficulties cultivating HIV advocacy groups, as stigma is widespread, little regard for individual rights exists (people are often testing unknowingly for HIV when they go for regular checkups (!!)), and ARVs are not affordable to the average Russian.
Harm reductions programs, namely distribution of clean needles to drug users, is the primary response by NGO's yet this has only contributed to increasing stigmatization of these groups.
For me the most interesting, and terrifying, part of this chapter was D'Adesky's description of the treatment of orphans. HIV positive infants who are orphaned (or abandoned) are housed at Children's hospitals. These hospitals, like much of Russia, are understaffed and underfunded. Increasing the problem, is the government's mandate to keep these infants in the hospital until they test negative for HIV. (Oftentimes, newborns carry passive maternal HIV antibodies that are shed within 18 months.) These infants stay in hospitals wards for months and many show signs of delayed development-which is common for institutionalized youth.
Like Tonya Thurman mentioned in her lecture, there is a growing movement away from orphanages and other institutionalized settings. Again, given the cultural context and stigma associated with HIV in Russia it seems unlikely that the government will shift to a model of community-based care. Which come to think of it is rather ironic given the underlying concept of communism.
Tuesday, May 6, 2008
Summertown or Carletonville?
I was under the impression that Summertown and Carletonville were the same place. Same project. Same outcome. Yet the picture painted by D'Adesky of this project is drastically different from the one depicted by Catherine Campbell in "Letting them Die."
D'Adesky touts the Carletonville AIDS project as a major success peer education programs, the intense focus on STI's, mass distributions of condoms, and high community involvement...She writes, "The PPT program's initial results were already encouraging in 2000." (p. 196)
I believe these are the same programs that Campbell describes here when she writes, "many of its proposed goals have yet to be implemented, consistent and widespread condom use remains low, and many project participants feel exhausted and demoralized." (Campbell, p. 185) As Campbell points out, condoms were distributed and sex workers, miners and youth were educated about proper use and importance but that didn't necessarily translate into condom use. Many sex workers would use them initially with a client, but as the relationship became more regular they discontinued use. Miners on the other hand experienced stressful and dangerous situations on the job daily, so whats one more risk.
Maybe in an attempt to gloss over the non-rosy realities of the situation, D'Adesky spends the remainder of the chapter discussing the role of business in HIV treatment/prevention programs. She encourages the emergence of big corporations into the global AIDS arena, and praises the work of businesses such as Heineken, Pfizer and Viacom for their financial contributions to the effort.
Again, here she seems to be living on a different planet than Campbell, who criticizes the lack of long-term commitment of the business community, as well as the lack of sustainability of the projects.
Who is right? I think both in a way. Campbell is overly critical of the business contribution to HIV programs. Money is too little, too slow, with too many strings attached. Yet there is much needed money coming in, and the concept of Corporate Responsibility is gaining strength. A conference on the role of big business in achieving the Millennium Development goals will be held this week, as politicians and corporations come together to highlight achievements and call for renewed support for humanitarian programs. And while I generally tend to agree with Campbell's more realistic version of SummerCarletonvilletown (?!) I think that D'Adesky does make a key point in this chapter; Treatment is the only short-term intervention for HIV available at this point. ARV's have allowed the AngloGold mine employees to return to work, reducing the loss of productivity that comes from sickness. This short-term intervention is exactly the short-term monitory support by businesses can provide. In fact, maybe that is the solution. Businesses can fund soley treatment programs, while governments and humanitarian organizations allocate their resources towards prevention programs.
D'Adesky touts the Carletonville AIDS project as a major success peer education programs, the intense focus on STI's, mass distributions of condoms, and high community involvement...She writes, "The PPT program's initial results were already encouraging in 2000." (p. 196)
I believe these are the same programs that Campbell describes here when she writes, "many of its proposed goals have yet to be implemented, consistent and widespread condom use remains low, and many project participants feel exhausted and demoralized." (Campbell, p. 185) As Campbell points out, condoms were distributed and sex workers, miners and youth were educated about proper use and importance but that didn't necessarily translate into condom use. Many sex workers would use them initially with a client, but as the relationship became more regular they discontinued use. Miners on the other hand experienced stressful and dangerous situations on the job daily, so whats one more risk.
Maybe in an attempt to gloss over the non-rosy realities of the situation, D'Adesky spends the remainder of the chapter discussing the role of business in HIV treatment/prevention programs. She encourages the emergence of big corporations into the global AIDS arena, and praises the work of businesses such as Heineken, Pfizer and Viacom for their financial contributions to the effort.
Again, here she seems to be living on a different planet than Campbell, who criticizes the lack of long-term commitment of the business community, as well as the lack of sustainability of the projects.
Who is right? I think both in a way. Campbell is overly critical of the business contribution to HIV programs. Money is too little, too slow, with too many strings attached. Yet there is much needed money coming in, and the concept of Corporate Responsibility is gaining strength. A conference on the role of big business in achieving the Millennium Development goals will be held this week, as politicians and corporations come together to highlight achievements and call for renewed support for humanitarian programs. And while I generally tend to agree with Campbell's more realistic version of SummerCarletonvilletown (?!) I think that D'Adesky does make a key point in this chapter; Treatment is the only short-term intervention for HIV available at this point. ARV's have allowed the AngloGold mine employees to return to work, reducing the loss of productivity that comes from sickness. This short-term intervention is exactly the short-term monitory support by businesses can provide. In fact, maybe that is the solution. Businesses can fund soley treatment programs, while governments and humanitarian organizations allocate their resources towards prevention programs.
Monday, May 5, 2008
Islam follow up....
After posting my last entry, I can across an interesting article in Atlantic Monthly about homosexuality in another Islamic country, Saudi Arabia, "The Kingdom in the Closet".
It gives a realistic portrait of what being "gay" in the Middle East means...which actually doesn't mean you are gay in the western sense at it all, it just means that you occasionally like to have sex with men. (Even if you are married with children)
For me, the most interesting part of the article was the concept that sex is not necessarily defined in terms of "homosexuality" or "heterosexuality" but rather between "taking pleasure" or "being used for pleasure." Not only is this concept disturbing to me as a woman, but the implications it means in the context of HIV. By viewing sex in terms of power and pleasure, rather than love or compassion, prevention methods of negotiation, faithfulness and trust will be ineffective.
Treatment programs better scale up in the region, because if this attitude continues to prevail there will be a lot of HIV floating around!
If for some reason the link did not work to to:
www.theatlantic.com/doc/200705/gay-saudi-arabia
It gives a realistic portrait of what being "gay" in the Middle East means...which actually doesn't mean you are gay in the western sense at it all, it just means that you occasionally like to have sex with men. (Even if you are married with children)
For me, the most interesting part of the article was the concept that sex is not necessarily defined in terms of "homosexuality" or "heterosexuality" but rather between "taking pleasure" or "being used for pleasure." Not only is this concept disturbing to me as a woman, but the implications it means in the context of HIV. By viewing sex in terms of power and pleasure, rather than love or compassion, prevention methods of negotiation, faithfulness and trust will be ineffective.
Treatment programs better scale up in the region, because if this attitude continues to prevail there will be a lot of HIV floating around!
If for some reason the link did not work to to:
www.theatlantic.com/doc/200705/gay-saudi-arabia
Sunday, May 4, 2008
Morocco
Morocco was my first international travel experience so I read this chapter with interest. As a 16 year old I lived in Morocco for a month baby-sitting my two younger cousins. I came away with several lasting impressions from the trip: Poverty...we lived in a nice residential compound but the second we stepped outside the gate there were hundreds of families camped outside, begging, digging through dumpsters, and just staring blankly at us as we drove by in our shiny volvo. Second impression: women weren't allowed in certain areas, certain cafes, and I never saw a woman's legs. Coming from America in the height of the mini-skirt craze this was shocking to me. The third thing I remember is our tour guide stopping in the middle of our tour, pulling down his pants and relieving himself two feet from me on the castle wall....Two of the three were indirectly addressed by D'Adesky in this chapter.
In her portrait of Morocco, D'Adesky makes a case for treatment that I hadn't really considered before. An Islamic country, the topic of HIV is often a taboo subject in Morocco due to its connection with homosexuality, bisexuality at promiscuity. As such, prevention measures have minimal and the leadership largely mute on this topic. Until now. While the epidemic is still relatively tiny in Morocco (according to UNAIDS, as of 2005 there are an estimated 19,000 people living with HIV), the Moroccan health officials hope to launch a bold experiment.
They hope that by initiating a national treatment plan for HIV, they can can not only bridge HIV prevention efforts, but actually serve as a prevention tool. By combining treatment with expanded HIV counseling services, advocates argue that it will spur those who are now afraid to get tested, as well as help doctors identify patients at earlier stages of infection. Health officials will then be able to target prevention efforts to stem potential outbreaks.
Some argue that Islam's ban on homosexuality and extramarital affairs has helped curb the rates of HIV in the Islamic world. While this may have contributed to the slow development of the disease in Morocco, it may have devastating effects once HIV reaches the broader community. The ban on homosexuality typically causes men to live secret double lives as they often give in to societal pressures and get married. Islamic law also permits men to have more than one wife which could also lead to rapid spread of the disease. As we learned from Helen Epstein's lecture, long-term concurrent sexual relationships have been a primary driver behind the epidemic's rapid spread. The low status of women in much of Moroccan society leaves them virtually powerless to make demands, or refuse their husbands. This makes women particularly susceptible to the virus.
One main theme of the course is the importance of cultural sensitivity when developing HIV programs. I think the Moroccan case study is an interesting example of how to deal with such a culturally sensitive issue. According to D'Adesky, the National government has steered clear of national media campaigns, instead targeting cities and commercial sex workers (who actually make up only a small percentage of women that are infected) because of the stigma associated with AIDS. Media is subject to censorship by state and religious groups, and references to sexuality are often forbidden. By focusing on treatment, the government is able to sidestep the issue of sexuality.
According to Professor Hakima Himmich, "stigma can change with access. The minute a mortal disease becomes a chronic one that you can treat, this is where you will see the change happen. It's clear you can't have an effective prevention strategy without access to care for affected people."
It will be interesting to see if this treatment model works. Because it was initiated while HIV was still relatively contained in Morocco, it may have a better chance of succeeding, yet it will be difficult to replicate in countries where the epidemic has all ready spread. I still remain skeptical of relying entirely on treatment measures to contain the epidemic. While it may help reduce the stigma associated with the disease, I think treating HIV like a chronic disease is dangerous. People feel healthy, and will not take as many measures to protect themselves, and HIV will continue to spread. As I mentioned earlier, it is only a matter of time before the virus mutates into another treatable form.
D'Adesky still hasn't sold me on the treatment model...
In her portrait of Morocco, D'Adesky makes a case for treatment that I hadn't really considered before. An Islamic country, the topic of HIV is often a taboo subject in Morocco due to its connection with homosexuality, bisexuality at promiscuity. As such, prevention measures have minimal and the leadership largely mute on this topic. Until now. While the epidemic is still relatively tiny in Morocco (according to UNAIDS, as of 2005 there are an estimated 19,000 people living with HIV), the Moroccan health officials hope to launch a bold experiment.
They hope that by initiating a national treatment plan for HIV, they can can not only bridge HIV prevention efforts, but actually serve as a prevention tool. By combining treatment with expanded HIV counseling services, advocates argue that it will spur those who are now afraid to get tested, as well as help doctors identify patients at earlier stages of infection. Health officials will then be able to target prevention efforts to stem potential outbreaks.
Some argue that Islam's ban on homosexuality and extramarital affairs has helped curb the rates of HIV in the Islamic world. While this may have contributed to the slow development of the disease in Morocco, it may have devastating effects once HIV reaches the broader community. The ban on homosexuality typically causes men to live secret double lives as they often give in to societal pressures and get married. Islamic law also permits men to have more than one wife which could also lead to rapid spread of the disease. As we learned from Helen Epstein's lecture, long-term concurrent sexual relationships have been a primary driver behind the epidemic's rapid spread. The low status of women in much of Moroccan society leaves them virtually powerless to make demands, or refuse their husbands. This makes women particularly susceptible to the virus.
One main theme of the course is the importance of cultural sensitivity when developing HIV programs. I think the Moroccan case study is an interesting example of how to deal with such a culturally sensitive issue. According to D'Adesky, the National government has steered clear of national media campaigns, instead targeting cities and commercial sex workers (who actually make up only a small percentage of women that are infected) because of the stigma associated with AIDS. Media is subject to censorship by state and religious groups, and references to sexuality are often forbidden. By focusing on treatment, the government is able to sidestep the issue of sexuality.
According to Professor Hakima Himmich, "stigma can change with access. The minute a mortal disease becomes a chronic one that you can treat, this is where you will see the change happen. It's clear you can't have an effective prevention strategy without access to care for affected people."
It will be interesting to see if this treatment model works. Because it was initiated while HIV was still relatively contained in Morocco, it may have a better chance of succeeding, yet it will be difficult to replicate in countries where the epidemic has all ready spread. I still remain skeptical of relying entirely on treatment measures to contain the epidemic. While it may help reduce the stigma associated with the disease, I think treating HIV like a chronic disease is dangerous. People feel healthy, and will not take as many measures to protect themselves, and HIV will continue to spread. As I mentioned earlier, it is only a matter of time before the virus mutates into another treatable form.
D'Adesky still hasn't sold me on the treatment model...
Saturday, May 3, 2008
Cuba: A poster child?
Cuba has an interesting method of dealing with HIV infections. Despite international protests, in 1986 Cuba initiated a quarantine policy that kept people with HIV apart from the general public in a sanatorium.
While now the forced quarantine has been lifted, people who test positive for HIV are required to take a three month course on living with HIV and on the importance of protecting others from exposure. Cuba has been viewed as the "poster child of prevention" both having reduced the spread of HIV and gained control of the epidemic, with one of the lowest HIV incidence rates in the world. Yet at what cost? A fine line exists between too much government intervention affecting privacy and good public health, yet where do we draw the line? Whose rights are more important, the individual rights or community rights?
D'Adesky writes about "Cheo", an HIV positive gay male who was diagnosed with the disease in 1993. For two years the government tried to pressure him into living at the Sanatorium, at one point they even threatened arrest. The attack on the personal freedoms of Cheo is not an isolated case. Other PLHIV face the same constraints in Cuba. But as the statistics support, this method of isolation and mandatory education programs has been instrumental in quelling the epidemic in Cuba. By limited the freedoms of a few (or more specifically 1,000 people), Cuba has protected the rest of its 11.5 million residents so that they are relatively more healthy.
This concept of restricting choices is not limited to Cuba. We see it here in the U.S. with increasing restrictions on smoking. In an increasing number of states, smokers are no longer allowed to smoke in public places such as bars, restaurants or the work place. These regulations are designed to improve the health of the greater community. Now not being able to light up a cigarette in your favorite neighborhood bar is slightly different than being forced to live in a sanatorium and have your every move monitored, but it shows that when making public health choices we most often side with the community.
One interesting note about Cuba is that Cubans put the responsibility of containing the AIDS epidemic on those with HIV, through education and by creating a code moral responsibility. And this approach appears to be working. Out of the 1,000 or so people that stayed at the sanatorium very few have infected others. The current climate of much of the western world is that we have a right to health care, or a right to education, without placing any sort of behavioral or moral obligations. Should people have access to a triple by-pass surgery if they continue to jeopardize their health immediately afterwards by eating a fast-food diet? I think Cuba is going in the right direction by not only educating people about how HIV is transmitted but also by conducting a kind of moral education as well.
Another thought that came to mind while reading this chapter was have the luxurious living conditions in the sanatorium actually created a perverse incentive to become infected with HIV? Dr. Jorge Perez Avila, who runs the national HIV treatment program, describes the good living conditions of the sanatorium. "They have a house, air conditioner, color TV, 100% of their salary and a diet very high in calories and rich in protein. No one else has that much." In fact when Cuba lifted the quarantine in 1993, only 10% of residents opted to leave when offered a chance. Given the now chronic nature of HIV since the improvements in ARVs would people be willing to trade their health for some air conditioning and local soap opera on TV?
At this point, this doesn't seem like a realistic concern, but as treatment continues to improve and class divides become exacerbated, we must be aware of the incentives the current treatment of PLHIVs is creating. I am by no means saying that we should start treating PLHIV poorly or send everyone to the streets, but I feel that isolating PLHIV and giving them certain privileges that others don't enjoy will create an "us" vs. "them" mentality that could provoke further stigma amongst the general population as well as encourage poorer populations to contract the disease.
While now the forced quarantine has been lifted, people who test positive for HIV are required to take a three month course on living with HIV and on the importance of protecting others from exposure. Cuba has been viewed as the "poster child of prevention" both having reduced the spread of HIV and gained control of the epidemic, with one of the lowest HIV incidence rates in the world. Yet at what cost? A fine line exists between too much government intervention affecting privacy and good public health, yet where do we draw the line? Whose rights are more important, the individual rights or community rights?
D'Adesky writes about "Cheo", an HIV positive gay male who was diagnosed with the disease in 1993. For two years the government tried to pressure him into living at the Sanatorium, at one point they even threatened arrest. The attack on the personal freedoms of Cheo is not an isolated case. Other PLHIV face the same constraints in Cuba. But as the statistics support, this method of isolation and mandatory education programs has been instrumental in quelling the epidemic in Cuba. By limited the freedoms of a few (or more specifically 1,000 people), Cuba has protected the rest of its 11.5 million residents so that they are relatively more healthy.
This concept of restricting choices is not limited to Cuba. We see it here in the U.S. with increasing restrictions on smoking. In an increasing number of states, smokers are no longer allowed to smoke in public places such as bars, restaurants or the work place. These regulations are designed to improve the health of the greater community. Now not being able to light up a cigarette in your favorite neighborhood bar is slightly different than being forced to live in a sanatorium and have your every move monitored, but it shows that when making public health choices we most often side with the community.
One interesting note about Cuba is that Cubans put the responsibility of containing the AIDS epidemic on those with HIV, through education and by creating a code moral responsibility. And this approach appears to be working. Out of the 1,000 or so people that stayed at the sanatorium very few have infected others. The current climate of much of the western world is that we have a right to health care, or a right to education, without placing any sort of behavioral or moral obligations. Should people have access to a triple by-pass surgery if they continue to jeopardize their health immediately afterwards by eating a fast-food diet? I think Cuba is going in the right direction by not only educating people about how HIV is transmitted but also by conducting a kind of moral education as well.
Another thought that came to mind while reading this chapter was have the luxurious living conditions in the sanatorium actually created a perverse incentive to become infected with HIV? Dr. Jorge Perez Avila, who runs the national HIV treatment program, describes the good living conditions of the sanatorium. "They have a house, air conditioner, color TV, 100% of their salary and a diet very high in calories and rich in protein. No one else has that much." In fact when Cuba lifted the quarantine in 1993, only 10% of residents opted to leave when offered a chance. Given the now chronic nature of HIV since the improvements in ARVs would people be willing to trade their health for some air conditioning and local soap opera on TV?
At this point, this doesn't seem like a realistic concern, but as treatment continues to improve and class divides become exacerbated, we must be aware of the incentives the current treatment of PLHIVs is creating. I am by no means saying that we should start treating PLHIV poorly or send everyone to the streets, but I feel that isolating PLHIV and giving them certain privileges that others don't enjoy will create an "us" vs. "them" mentality that could provoke further stigma amongst the general population as well as encourage poorer populations to contract the disease.
Thursday, May 1, 2008
What a TRIP
We now move on to the big, bad wolf...Big pharma.
In 1993, the a private Brazilian drug company, Microbiologics, began manufacturing a generic version of AZT. At this point, AIDS was spreading so quickly over the country that many predicted it would be the next South Africa. Yet over the next seven years, the company manufactured generics for other HIV drug regimens, and the government provided ARVs to PLHIV free of charge. This saved the health system an estimated $677 million, freed up thousands of hospital beds and cut AIDS deaths by over 70%. For more on the success of Brazil, check out the New York Times Magazine article: Look at Brazil.
Big pharma began to take notice. In 2001, the U.S. government filed a complaint with with the WHO to try and stop Brazil from making generic antiretrovirals and threatened trade sanctions if they failed to comply. According to D'Adesky, the U.S. was not as concerned about loosing their competitive edge on the ARV market, but were worried about patent laws that currently protected makers of new products under the Trade Related Aspects of Intellectual property and Public Health (TRIPS). If these laws were altered, big pharma concerned that other generic drugs could find their way into the international market as well.
Brazil fought back citing a 1997 patent law that allowed for the production of generics to to address a "national emergency." The U.S. ended up dropping the complaint, but Brazil kept on fighting. Not only did they threaten compulsory licensing to negotiate huge discounts for U.S. patented ARVs, but they led the way for other developing countries at a WTO conference in Doha, Qatar. Under the new Doha agreement, poorer nations facing national emergencies were allowed to circumvent patent rights for better access to essential medicines. However, these countries were still not allowed to export these generics, and it required them to develop the capacity to manufacture their own generics--something few are capable of. Drug production requires a substantial investment, industrial manufacturing base, and skilled manpower.
In theory, giving developing countries the capacity to produce generic drugs seems like the perfect plan. Along with Brazil, India, China, Cuba and Thailand have all built up their capacity to produce these drugs. However, few countries lack the raw materials or pharmaceutical ingredients used to make ARVs, so even if they did have the capacity it they would have to rely heavily on other countries for imports. Also, should the developing world get the capacity to manufacture drugs, it would be highly unlikely that they would be able to regulate the process on a large scale. The HIV virus is extremely sensitive, and can mutate into a more virulent form if not properly regulated. I fear that improperly made, or untested ARVs could lead to a new drug-resistant strain and need for second-line treatment that could be even more detrimental to the developing world. Also, would it be cost effective if every African country manufacture their own drugs? With more governments and organizations such as the Clinton Foundation actively intervening to negotiate for lower generic prices, it is not as necessary for these countries to manufacture drugs.
Just as a side note, in contrast to Brazil's policy of providing free ARVs to its citizens, South Africa’s national HIV treatment program has been very controversial. The South African government was initially hesitant about providing antiretroviral treatment to HIV-positive people, and only started to supply the drugs in 2004, (over 10 years after Brazil started providing ARV treatment) following pressure from activists. Even since 2004, the distribution of antiretroviral drugs has been relatively slow, with only around 33% of people in need receiving treatment at the end of 2006. (WHO) More on South Africa later in the blog...
In 1993, the a private Brazilian drug company, Microbiologics, began manufacturing a generic version of AZT. At this point, AIDS was spreading so quickly over the country that many predicted it would be the next South Africa. Yet over the next seven years, the company manufactured generics for other HIV drug regimens, and the government provided ARVs to PLHIV free of charge. This saved the health system an estimated $677 million, freed up thousands of hospital beds and cut AIDS deaths by over 70%. For more on the success of Brazil, check out the New York Times Magazine article: Look at Brazil.
Big pharma began to take notice. In 2001, the U.S. government filed a complaint with with the WHO to try and stop Brazil from making generic antiretrovirals and threatened trade sanctions if they failed to comply. According to D'Adesky, the U.S. was not as concerned about loosing their competitive edge on the ARV market, but were worried about patent laws that currently protected makers of new products under the Trade Related Aspects of Intellectual property and Public Health (TRIPS). If these laws were altered, big pharma concerned that other generic drugs could find their way into the international market as well.
Brazil fought back citing a 1997 patent law that allowed for the production of generics to to address a "national emergency." The U.S. ended up dropping the complaint, but Brazil kept on fighting. Not only did they threaten compulsory licensing to negotiate huge discounts for U.S. patented ARVs, but they led the way for other developing countries at a WTO conference in Doha, Qatar. Under the new Doha agreement, poorer nations facing national emergencies were allowed to circumvent patent rights for better access to essential medicines. However, these countries were still not allowed to export these generics, and it required them to develop the capacity to manufacture their own generics--something few are capable of. Drug production requires a substantial investment, industrial manufacturing base, and skilled manpower.
In theory, giving developing countries the capacity to produce generic drugs seems like the perfect plan. Along with Brazil, India, China, Cuba and Thailand have all built up their capacity to produce these drugs. However, few countries lack the raw materials or pharmaceutical ingredients used to make ARVs, so even if they did have the capacity it they would have to rely heavily on other countries for imports. Also, should the developing world get the capacity to manufacture drugs, it would be highly unlikely that they would be able to regulate the process on a large scale. The HIV virus is extremely sensitive, and can mutate into a more virulent form if not properly regulated. I fear that improperly made, or untested ARVs could lead to a new drug-resistant strain and need for second-line treatment that could be even more detrimental to the developing world. Also, would it be cost effective if every African country manufacture their own drugs? With more governments and organizations such as the Clinton Foundation actively intervening to negotiate for lower generic prices, it is not as necessary for these countries to manufacture drugs.
Just as a side note, in contrast to Brazil's policy of providing free ARVs to its citizens, South Africa’s national HIV treatment program has been very controversial. The South African government was initially hesitant about providing antiretroviral treatment to HIV-positive people, and only started to supply the drugs in 2004, (over 10 years after Brazil started providing ARV treatment) following pressure from activists. Even since 2004, the distribution of antiretroviral drugs has been relatively slow, with only around 33% of people in need receiving treatment at the end of 2006. (WHO) More on South Africa later in the blog...
Wednesday, April 30, 2008
Why is AIDS so Sexy?
As I read the next chapter, AIDS and Empire, which describes the recent "global treatment revolution" which began in 1998 and continues to this day, I began thinking about a question that came up in our group discussion on the last day of class. Why HIV? Why has this disease captured the attention of the international community more than any other over the last decade?Malaria kills more people annually every year. So does Cancer. In 2007, 7.6 million people died of cancer. (American Cancer Society)
Is it because of Bono? Is sex just sexy? Or is it what the book is implying. The late 1990's with the improvement in quality of antiretrovirals combined with increased pressure on Congress by small activist groups led to a tangible, benchmarkable concept that politicians all over the world were able to get behind. The 3 x 5 Program. To treat 3 million Persons Living with HIV (PLHIV) by 2005. While it wasn't a vaccine, the world could now put money into a cause that had made the disease manageable in the developed world.
Yet beware. Is all this support truly genuine? President Bush surprised the world by pledging $15 billion to global AIDS efforts. However, it later became evident (according to the author, and I tend to agree) that the president's PEPFAR initiative was designed to a) sabotage the multilateral UN-back Global Fund. b) funnel more money into his core constituency of faith-based organizations that support abstinence only programs over the use of condoms. c) opens the market to big pharma to market their brand name drugs to the developing world.
AIDS is sexy at the moment, but as D'Adesky implies, it provides an altruistic cover for the developed world to quietly push their own agendas. While the current level of support and attention to AIDS is crucial to the developing world, who clearly doesn't have enough resources to provide services, both preventative and clinical, to address HIV on their own, efforts should be made to build the capacities of these governments so they don't become dependent on the western world for treatment.
So thats a rather pessimistic view of why AIDS is sexy at the moment. It is sexy because governments can hide their own personal agendas behind it? Well, maybe. But I think its a simpler matter, and it's the reason why I want to work in this field: we are all susceptible to it. Unlike Cancer where one may be genetically predisposed to get it, or malaria which is only concentrated in tropical climates, HIV is found everywhere. Not one country is not feeling the effects of this disease in one way or another. Yet, it is not a fair disease. In the developing world it is generally found in areas of extreme poverty, areas with low levels of education, areas with gender inequalities. These are issues that need to be addressed. Yes I want to work with HIV prevention programs, but I want to use HIV and the political and economic support it has gained in recent years to mask my own personal agenda of development.
Tuesday, April 29, 2008
We'll Start with a Foothill
Harsh. Plague. There is Hope. Darkness. Invisible. Silence. Black. Deadly. Deception. Combat. Mountains.
So I'm exaggerating a little. The introduction wasn't that bad, but I'm sick of every AIDS book, every AIDS article, and as Dr. Thurman mentioned in her lecture, every grant proposal using the same formula: A heart wrenching story, catastrophic numbers, followed by what we are doing wrong. I'm not sure I have the answer for how we should frame this epidemic, and hey, maybe that formula is working...AIDS is the trendy, fundable disease at the moment. It just seems like we have been following the same blueprint for years, with little success in actual decline in HIV infections. As we see from the recent UNAIDS statement: the"epidemic is outpacing the response."
1. Summarize and analyze the various country case studies presented in this book.
2. Treatment is ok....but is it sustainable? is it taking away funds from prevention?
3. Come up with a better way to start an AIDS book. (we'll see.....)
4. (Hopefully) link this book to several of the main themes touched on in class: "the West's" role in providing aid, individual vs. community rights, culturally appropriate messages, and the role of ARVs in this "fight"
5. Provide a mildly entertaining/interact format in which to address these issues.
Hmm...Are these the thoughts going through my head while attempting to start up a new blog? Well, kind of. But they also represent a few key words in the titles of books depicting the harsh, deadly, dark, yet invisible mountain called HIV that we must combat or face certain annihilation of all mankind. I don't mean to be so over the top, but I had high hopes when I began the book "Moving Mountains: the Race to Treat Global AIDS" by Anne-Christine D'Adesky. Yet after reading the introduction I feel a little discouraged. It begins with a classic sob story:
Once upon a time in a desolate shantytown in Haiti, surrounded by abject poverty and a loving family, a man who was once a brilliant, brave AIDS activist stands vulnerable and delirious before us. And then he dies. It then goes on to talk about the 25 million people who have died of AIDS, and the 42 million affected with the virus, but make sure to note that 35 million of the 42 million are from less developed countries, and 28 million of the 35 million of those people live in sub-Saharan Africa which come to think of it, we learned in class that the 42 million was inaccurate and that it was closer to 40 million and of those 40 million only 26 million lived in sub-Saharan Africa. Clear everyone?
Next, as we slowly trudge up the first foothill, we learn of another woman who may die due to lack of ARVs and of the thousands that lack needed medications. We then learn about the costliness of ARV treatment, and the ugly profit motives of drug companies. Luckily we reach a plateau of hope with the influx of new Western humanitarian aid leveraged at AIDS groups but we start trekking again past the 6 million people in need of ARVs, toward the "doomsday" of dried up funds, weak infrastructures, stigma, and inequalities. Finally, as we approach the peak (of the introduction), we are urged not to jump yet, because interesting models from India, Cuba, South Africa and Russia that are right around the bend...
So I'm exaggerating a little. The introduction wasn't that bad, but I'm sick of every AIDS book, every AIDS article, and as Dr. Thurman mentioned in her lecture, every grant proposal using the same formula: A heart wrenching story, catastrophic numbers, followed by what we are doing wrong. I'm not sure I have the answer for how we should frame this epidemic, and hey, maybe that formula is working...AIDS is the trendy, fundable disease at the moment. It just seems like we have been following the same blueprint for years, with little success in actual decline in HIV infections. As we see from the recent UNAIDS statement: the"epidemic is outpacing the response."
Anyway, I chose this book because it contains country case studies from across the globe. While Africa is certainly the focus (rightly so) of much of the AIDS efforts, many other parts of the world are coping with this "deadly plague" as well. Also, the author chooses to focus on the treatment approach to reduce stigma and mitigate the effects of the disease. Coming from the world of a Peace Corps health volunteer who saw prevention as the golden ticket, panacea for all the worlds problems I am interested to hear more about what treatment has to offer.
So.....My Objectives for this blog:1. Summarize and analyze the various country case studies presented in this book.
2. Treatment is ok....but is it sustainable? is it taking away funds from prevention?
3. Come up with a better way to start an AIDS book. (we'll see.....)
4. (Hopefully) link this book to several of the main themes touched on in class: "the West's" role in providing aid, individual vs. community rights, culturally appropriate messages, and the role of ARVs in this "fight"
5. Provide a mildly entertaining/interact format in which to address these issues.
I'll leave you with some tear jerking book cover images to keep you riveted and reaching for your pocketbook to donate to Save the Children until my next post....
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