August 4, 2008

Applying the Paradox of Prevention: Eradicate HIV

Major public education and information campaigns alerted Australians to the threat posed by HIV and told them how to prevent infection. Several clinical and social research institutions were funded, as were the main community organizations dealing with the disease. A national needle and syringe exchange program was introduced in every state, complemented by enhanced methadone replacement programs. Testing for infection was encouraged and covered under Medicare. Those with HIV and AIDS were given highly subsidized access to the latest treatments. Substantial legislative changes were made to protect people with HIV/AIDS from discrimination, especially discrimination related to employment and access to housing and other services.

This consolidated the progress in containing new infection rates among gay men and extended those gains to sex workers, injecting drug users and the general, heterosexually active, population. Rates of new infection, which had already started to come down in gay men, fell rapidly. Access to clean needles and syringes quickly reduced the worrying rise in infections among injecting drug users, and eliminated drug users as a vector by which HIV might have crossed over into the general population. Rates of testing and condom use increased dramatically. Tracking surveys indicated that knowledge about the disease, and the facts about its nature and transmission, improved considerably. Over time, incidents of discrimination against HIV-positive people decreased as ignorance and fear declined. Among high-risk groups, dedicated staff and volunteers worked tirelessly to spread the message about condoms and clean needles. The necessary financial and human resources were put behind a clear and unambiguous strategy. Annual rates of new HIV infections fell from 1,297 in 1988 to 986 in 1993. In 1998, the annual rates of new HIV infections in Australia fell to the historic low point of 645. Since then, the annual rate of new infections has increased to 928 in 2005 a rise that reflect the lack of sustained prevention campaigns directed at young people and perhaps a sense that HIV is no longer a mortal threat.

Over the years, some critics have maintained that the Australian response was so atypical as to be almost unique, and that it could therefore not be applied universally. Certainly, the quality and nature of the political leadership at government level, and across the affected groups, was exceptional. Australian politics and society are generally non-ideological and pragmatic. Organized religion does not generally have much political clout. In the 1980s, the moves towards a less judgmental and more tolerant attitude towards homosexuality, sex work and even drug usage greatly helped in this policy-making and also helped shape a distinctively Australian response. But the qualities of the virus are no different in Australia than elsewhere. By its nature, the HIV virus is susceptible to simple prevention measures based on relatively minor changes to sexual and other risky behaviors. The Australian difference was the political will to inform, educate and to provide the necessary simple technologies: condoms and clean needles.

By definition, HIV prevention must be directed not where the problem is, but where it is not – at younger, sexually active people and those most likely to experiment with injecting drugs (also most likely to be young). They are unlikely to visit clinics and hospitals, but they can be reached in schools, malls, workplaces, sporting and entertainment venues, and through television, radio, films, phones and the internet. Young people at greatest risk of infection won’t be found in churches, synagogues, mosques and temples, but in places where they can have sex and even do drugs. Many young people hang out in cyberspace. To work, HIV prevention messages must be delivered to young people where they are, in ways that make sense to them. Above all, prevention campaigns work best when they are stripped of moral judgments, and overt editorializing about virtue and social improvement.

In many countries, HIV prevention programs are being applied that are based on these precepts and strategies. International agencies and donors have increasingly funded such campaigns. There have been some notable recent success stories in, for example, Cambodia, as a result of mass prevention campaigns and promotion of condoms to young people, there are encouraging signs that HIV rates are falling.  In 2005 Taiwan responded to rapidly increasing rates of HIV infection among injecting drug users by introducing a needle exchange and methadone substitution program.  Infections that had risen rapidly from negligible levels in 2003 jumped to 2,500 new cases two years later, but after the new programs were introduced fell to about 1,700 the following year.

International agencies have funded and supported a range of effective prevention measures based on the undeniable evidence that such programs work. But, as the present rate of new infections demonstrates, the core problem is that – although effective – these prevention measures are not being implemented fast enough, widely enough, well enough or in enough jurisdictions to make a truly significant difference.

There is no constituency for HIV prevention that can remotely rival that advocating care, treatment and research. The care and treatment coalition determines priorities; convenes conferences and influence politicians, donors and the public debate about the allocation of scarce resources. Everyone with HIV and AIDS has, by definition, an urgent need for support. They will always have the first call on funding because they can demonstrate need. In crude terms, there is now a global constituency of forty million people directly affected by the virus, and another hundred million or so living with indirect economic and social burdens of the disease. In politics, numbers count. Politicians and bureaucrats ignore numbers and need at their peril.  Responding to the multifaceted and urgent need for care and treatment is more pressing than spending time and money on prevention. By its nature, those advocating prevention find very few seats at the top table, although the constituency of those at risk of HIV infection is far larger than those who require treatment. The social and economic benefits of these young people not contracting HIV are obvious but the political benefits are negligible. The urgent has trumped the important and generated a peculiar but real moral hazard.

What is now required is a considered economic case for the primacy and viability of prevention. The basic economic structure of health systems must be reconfigured to create incentives to prevent – incentives every bit as attractive as those that already exist in the system to create care, treat and research.  Those who say such a reform is impossible should contemplate the upheavals that are transforming the economic system in response to global warming. New systems of accounting, pricing and trading are being developed that will provide massive incentives to change behaviors and rebalance risk. New incentives to prevent will be created, and profits will accrue to those who do it best.

What is the difference between a molecule of carbon dioxide and a sliver of HIV virus? In economic terms, not much. Both are emitted, as it were, as by-products of human behaviors linked to the gratification of wants and needs. Both spread with no regard to borders, race, sex, gender, class, income, good intentions, age or any other human quality or attribute. Yet both can be controlled and contained by adjusting human behavior. The difference between the response to global warming and HIV/AIDS is simply how we have gone about persuading people to make the necessary alterations in their behaviors. We accept that the surest way to manage global warming is to create and manipulate economic incentives, costs and prices. This is surely what must be done in relation to the future control of HIV.

There are great possibilities for restructuring health systems to provide incentives to prevent, to reward risk and achieve clear targets and goals. If we can provide the right incentives and rewards, and couple them with public health messages that make sense to the most vulnerable groups of young people, the spread of HIV will be controlled far more effectively than any punishment, prohibition, injunction, fatwa or prayer has been able to. 

To read this essay in its entirety, click here.

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Previous Comments:

Matthew Mee, LONDON, 2008-08-11 12:59:56
I don't like the word "eradicate" for population based stuff. It means those of us already infected will have to die before HIV is truly eradicated. How about eradicating it first?!

anon, , 2008-08-10 06:13:47
I'm glad Australia is being looked at as a model for the rest of the world. But reservedly. Guess I must have missed the memo- or the guy who infected me.