Aid Watch, a blog I love and read often, posted “How the war on AIDS was lost” in response to a recent Wallstreet Journal article about AIDS treatment shortages and increased HIV incidence in Uganda. Both articles describe a shortage of AIDS treatment for the increasing HIV infections in sub-Saharan Africa, but then point to spending on treatment rather than prevention as the cause of increasing HIV infections.
I have worked in HIV/AIDS services for almost 5 years and what I know to be true, in the US and Uganda, is that treatment and prevention are interdependent. I also know that HIV/AIDS is a complex problem with social, economic, political and public health factors – a complex response is essential. There is not a silver bullet solution to HIV/AIDS. And prevention is difficult. The WSJ article praises the Bush administration for PEPFAR, but fails to acknowledge the misguided PEPFAR prevention policies that ignored evidence-based prevention practices in favor of ideology and may have contributed to increased HIV incidence in Uganda and other PEPFAR-funded countries. Finally, the WSJ article failed to mention the innovative and effective work of The AIDS Support Organisation (TASO), an indigenous AIDS service NGO in Uganda. TASO uses a community-based approach to provide care and services to Ugandans infected and/or affected by HIV/AIDS.
Paul Farmer has spoken out against the treatment vs. prevention debate. Here he describes the connection between structural violence and HIV, shedding light on the complexities of the HIV/AIDS epidemic and the need for a multi-faceted response (from Pathologies of Power):
HIV attacks the immune system in only one way, but its course and outcome are shaped
by social forces having little to do with actual virus… From the outset of acute HIV infection to
the end game of recurrent opportunistic infections, disease course is determined by, to cite but a
few obvious factors: (1) whether or not post exposure prophylaxis is available; (2) whether or not
the steady decline in immune function is hastened by concurrent illness or malnutrition;
(3) whether or not multiple HIV infections occur; (4) whether or not TB is prevalent in the
surrounding environment; (5) whether or not prophylaxis for opportunistic infections is reliably
available; and (6) whether or not antiretroviral therapy (ART) is offered to all those needing it.