Domesticating Global AIDS

If one counts from the first report from the Centers for Disease Control in June 1981, the AIDS epidemic is entering into its 25th year. There is little cause for celebration. A few short decades ago, many epidemiologists believed that they were winning the war on infectious diseases. The emergence and persistence of AIDS – as well as the recurrence of other serious infectious diseases such as tuberculosis, malaria and measles -- has shown how wrong they were and how vulnerable we are. The most recent report released by UNAIDS hardly paints a rosy picture:

-- Number of people living with HIV in 2005: approximately 40.3 million
-- Number of people newly infected with HIV in 2005: approximately 4.9 million
-- Number of AIDS deaths in 2005: approximately 3.1 million

It is also clear from the report that some of us are far more vulnerable than others. Impoverished developing world countries marked by oppression, civil conflict, corruption, famine or overpopulation provide ecological niches for infectious agents like HIV. Of the 40.3 million living with HIV in 2005, 25.8 million live in sub-Saharan Africa, which also accounts for 2.4 million AIDS deaths in 2005.

Against this background, a sounding board article (‘Applying Public Health Methods to the HIV Epidemic’) in the New England Journal of Medicine published on this World AIDS Day makes for disturbing reading. In it, the authors advocate the use of standard disease control methods against HIV/AIDS, including routine HIV testing and partner notification. For those unfamiliar with these terms, routine (or ‘opt out’) HIV testing means the integration of HIV testing into hospital practice, like testing for hypertension; the patient is told he/she will be tested for HIV unless he/she refuses. Partner notification means that when a patient tests positive for HIV, the sexual partner of the patient will also be told the test result. These measures, according to the authors, were not taken earlier in the epidemic when there was no treatment and no legal protections against discrimination. But now that the latter exist, the time to bring in these methods is now: the time of ‘AIDS exceptionalism’ is over.

The arguments for routine testing and partner notification are not what is most disturbing about the article. It is rather that on World AIDS Day, the New England Journal of Medicine sees fit to publish a prominent opinion paper on public health approaches to HIV/AIDS that is entirely focused on the epidemic within America’s borders, when the its share of global deaths due to HIV/AIDS stands at 0.5%. Are practices like routine testing and partner notification to be recommended for the countries with the highest burden of disease, where access to treatment is currently dismal and legal protections against discrimination virtually non-existent? In such settings, should concerns about confidentiality and stigmatization be trumped by public health methods aiming at the most efficient control of disease? How should the balance between individual lives and population-level disease control be struck? These are crucial questions in the struggle against global AIDS, but they cannot be answered by an opinion paper that is apparently only really meant for domestic consumption.