No Choice Between AIDS Prevention and Treatment

Published in: Hartford Courant, 16 July 2001

The recent U.N. General Assembly Special Session on HIV/AIDS represents a watershed in international awareness of the nature and impact of this global epidemic.

Despite this awareness, however, a good number of serious misconceptions about the nature of this disease persist. Take Andrew Natsios, the new administrator of the U.S. Agency for International Development.

In an interview with the Boston Globe last month, Natsios rejected the use of anti-retroviral drugs in Africa not only because the general infrastructure for the efficient delivery of such drugs is lacking in many places but also because Africans “don’t know what Western time is” and thus cannot follow the strict regimen required for such treatments.

Instead, Natsios proposed using the resources of the Global AIDS and Health Fund currently being established for prevention alone.

Such assertions coming from the top of the Bush administration are worrisome for two reasons. First, they ignore the increasing evidence that even poor countries can effectively manage the treatments currently available for patients with HIV/AIDS.

Brazil, for one, has established a system of clinics that reach even the poorest of the poor and provide them with drugs. As Tina Rosenberg reported in The New York Times in January, the compliance with complex treatment plans even among illiterate slum dwellers in Brazil was no different than that found in San Diego.

The biggest obstacle to effective treatment plans is not the sophistication of the patients, but the cost of drugs and the willingness of governments to implement an effective delivery system. With the pharmaceutical industry finally being forced to lower its prices of anti-retroviral drugs, it is now possible to plan effective treatment strategies even in poor countries.

The second reason for the shortsightedness of Natsios’ position is the rather narrow manner in which he defines prevention.

Inevitably, prevention is couched in terms of behavioral change. Safe sex education, abstinence and condom use are all examples of such a narrow view of prevention. These, of course, are important aspects of any strategy to combat this pandemic.

However, the unspoken assumption lurking behind this view is that the high rate of infection in many parts of Africa is the result of unchecked sexual practices that differentiate Africans from the rest of the world.

This view is not at all new; the history of slavery and racism has always included many myths about African sexuality. But this is the 21st Century. Can we really believe that different rates of unprotected sex are the sole reason to explain an infection rate in Botswana that is more than 50 times that of the United States?

For all we know, there is as much unprotected sex in the United States as there is in any given African country. UNAIDS, in a 1999 study, has come to the conclusion that there is no correlation between rates of sexual behavior and rates of HIV infection.

What is missing from the AIDS debate is how poverty and differential social status affect the prevalence of AIDS. A healthy, well-fed male is much less likely to contract HIV through unprotected sex than someone whose immune system is already compromised as a result of malnutrition, unclean drinking water, lack of even rudimentary medical care and the various diseases that inevitably thrive in such environments.

Women are in an even worse position. In addition to poverty, they must deal with their inferior social status and gender bias. UNAIDS reports that widespread violence against women, differential access to education and prostitution as a means to escape poverty all play a role in making women and teenage girls even more vulnerable to the virus.

So prevention is more than using a condom; it requires broad-based efforts to eradicate poverty that make human rights a reality for all.

It is highly unlikely that Natsios had this in mind when he advocated prevention over treatment. In his mind, and by extension in the minds of others in this administration, this stance is primarily driven by cost considerations. Unwilling to pledge more than $200 million to the Global AIDS and Health Fund, the United States now advocates behavioral change as cheaper than treatment.

I will not comment on the moral implications of condemning the 24.5 million people now living with HIV/AIDS in Africa to certain death. However, the choice between prevention and treatment is a false one. Both are necessary and both are expensive.

Ignoring this reality will only exacerbate the pandemic. If the United States indeed aspires to world leadership, this is one place to start.

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