|Bill Bowtell, HIV/AIDS Project director with the Lowy Institute for International Policy|
In the very early years of the AIDS epidemic, Australia developed a response to the potential threat of HIV that kept tens of thousands of young people alive and free of infection. The response was not an antidote, but a vaccine. Not a vaccine of the body, but of the mind. In Australia, the vaccine that brought HIV under control was behavioral prevention. The spread of the virus was contained because people made simple changes to risky behaviors, persuaded to do so by the timely mass distribution of honest and useful information about the nature of the virus and how its transmission from person to person could be prevented.
The Australian response worked astonishingly well. In 1983, Australia, North America and Western Europe had roughly comparable rates of HIV infections and AIDS cases. From the mid-1980s on, however, Australia pursued policies that were radically different from those adopted in the United States which opted for harsh, punitive policies that often demonized the virus as a divine punishment for sin. The American government refused to implement needle and syringe exchanges to provide uninfected equipment to injecting drug users, or to sanction national sexual education campaigns and condom distribution. Notoriously, President Ronald Reagan only once uttered the word “AIDS” during his entire eight-year presidency from 1981, when American cases of HIV grew from almost none to nearly a million.
After two decades of applying radically different policies, the American and Australian outcomes are, hardly surprisingly, radically different. Twenty five years on, Australia’s rate of HIV prevalence is 75 per hundred thousand, compared with 402 per hundred thousand in the United States. Australia’s incidence of AIDS per hundred thousand is 1.3 compared with 14.3 per hundred thousand in the United States.
As we look back over a generation, we can see how radical, inspired and effective this response was. For little more than $100 million a year (in 2007 dollars) outlaid over twenty years to cover all HIV-related care, treatment, prevention and research, the domestic threat of HIV/AIDS was contained. Australia produced by far the best outcome of any comparable country. However success is an orphan while defeat has a thousand fathers. With a laconic shrug of the shoulders, Australia’s success in containing HIV/AIDS is taken for granted. The great achievement has fallen victim to the paradox of prevention – if it is done well, its success is not apparent.
The global response has coagulated around an unexceptional negative proposition: the fight against AIDS. The trouble is that this fight has been hijacked by forces pursuing entirely different goals: the suppression of vice and the promotion of virtue. The decision-makers in the global struggle have deluded themselves that HIV can be contained only by a vast upheaval of deeply-rooted social norms and beliefs. Rather than focusing on the specific problem of preventing the transmission of HIV, we have been inveigled into a war against human nature. The consequences of these well-meaning but destructive strategies are now completely apparent. It is not possible to win a war against vice. It is ludicrous to pretend that the virus can be destroyed by denying the sexual lives of human beings. This is a virus, not a sin.
Since the late 1980s, the ostensible objective of the global HIV/AIDS strategy has been to mobilize opinion and resources behind a “war on AIDS”. Who could not support such a fight? But the war on AIDS is compromised by the same linguistic flaws, political spin and hopeless confusion of means and ends as the other wars on abstractions: the “wars” on poverty, illiteracy, child abuse, discrimination, racism, cancer, terrorism, depression, crime and all the other ills of our times. Real wars against physical enemies corral every resource in pursuit of a clear outcome as rapidly as possible. In contrast, Orwellian wars on abstractions, including AIDS, are endless without achievable goals. The purpose of these “wars” is funding the perpetual struggle, not the elimination of the problem.
After so many years of global failure, so many unnecessary and avoidable deaths, it is time to abandon the childish idea that we are engaged in a struggle against evil in the form of a virus. Rather, it is time to define a single, clear positive goal: the complete eradication of HIV from the planet. To achieve this goal will require a fundamental change in the present, confused global strategy that has failed either to meet the challenge of providing for the care and treatment of people with HIV and AIDS or, more importantly, to prevent the spread of the HIV virus.
For a time, it seemed sensible to see the problems of care and treatment and prevention as best dealt with as one within a single intellectual and organizational framework. But the urge to merge HIV and AIDS that occurred in the middle years of the epidemic can now be seen to have been a strategic error with seriously adverse consequences for the effective management of the global problem. The understandable desire to deal with all aspects of the pandemic within one framework prioritized care and treatment over prevention. These consequences were neither foreseen nor intended, but created an impressive moral hazard and a set of perverse incentives that is paradoxically now encouraging the global growth of HIV and AIDS cases.
The immense cost of providing universal access to care and treatment will inevitably require that the growth in new caseloads be capped by successful prevention strategies. If HIV can be prevented, it must also, eventually, be able to be eradicated through a combination of behavioral and biomedical interventions. The case for the universal eradication of HIV within three generations – by the turn of the century – and for separating the responses to HIV and AIDS is based on the lessons I derive from the Australian experience of HIV.
By late 1983, gay men in Sydney and Melbourne had formed ad hoc HIV support and information groups. They assured the government that it was feasible to promote the use of condoms for anal sex, and to persuade gay men to take reasonable risk-reduction measures. Sex workers and injecting drug users formed similar groups. Discussions with them also indicated a high degree of willingness to consider and advocate behavioral change, but only to the degree necessary to minimize the risk of HIV transmission. They made it clear there would be strong resistance to any measures to further increase the marginalization of gay men, sex workers or drug users and that, in terms of reducing transmission, further oppression would be futile and counter-productive. The scientific evidence showed that the virus was not overly contagious, and our discussions with at-risk groups indicated that they comprised responsible citizens willing and able to educate their peers about moderating risky behaviors. What was required was a comprehensive national prevention strategy. Effective policies needed to be funded and applied and technologies provided to allow people to protect themselves and their partners from possible infection.
By the mid-1980s, we were satisfied that prevention was both theoretically possible and practically achievable. Minimizing the risk of sexual transmission required the widespread promotion and distribution of condoms; minimizing the risk of blood-borne infection required the blood supply for transfusions and in clinical settings to be routinely tested and sterile needles and syringes made available to those who were using drugs illicitly. By 1986 we were confident that the networks existed to disseminate information, advice and equipment and that a total commitment to HIV prevention should be tried and could bring about substantial and sustained reductions in new cases.
Yet the forces of resistance to prevention were also gaining in strength. They claimed that sustained prevention was not possible and at-risk groups could not be relied on to change their behavior. They were opposed to the introduction of needle and syringe exchanges on the grounds that such measures would lead to an increase in drug use, and therefore an increase in new HIV infections. They were adamantly opposed to any measures that accepted the reality of homosexuality. The Catholic Church especially rigidly opposed the use or promotion of condoms, even to prevent infection in heterosexuals, and Pope John Paul II denounced what he called the “objective disorder” of homosexuality.
It was impossible and undesirable to reconcile these two positions. Either we opted for comprehensive HIV prevention or abandoned it entirely, as had occurred in the United States. In April 1987, the Australian government opted to support a radical package of HIV prevention measures. These policies comprised:
- timely, peer-based, direct and explicit preventive education campaigns directed both at high-risk groups and the general public;
- widespread introduction of subsidized needle and syringe programs and rapid expansion of methadone maintenance treatment;
- access to free, anonymous and universal HIV testing;
- subsidized access to anti-retroviral treatments;
- general advocacy of the need to adopt safer sexual practices, especially the use of condoms; and
- widespread availability of condoms and targeted safe sex messages.
These policies were in turn based on long-term thinking; the primacy of empirical research and evidence in making policy; the need to minimize risk to the general population; recognition of the importance of research, especially epidemiology, clinical treatment, retro virology and social science; respect for human rights buttressed as required by legislation; and collaboration and partnership between all stakeholders. The 1987 package funded the states and territories to deliver HIV and AIDS care, treatment and prevention services. It was the end result of a continuous social and political debate that had raged for four years. As in the United States, the debate was at times overwhelmed by the link between the virus and anal sex and injecting drug use, yet the evidence pointed to the feasibility and desirability of HIV prevention. This required the government to recognize the reality of sexual diversity and the widespread use of illicit drugs, and to confront the world as it was, not as some would wish it to be, and fashion pragmatic policies accordingly.