The virtues and perils of putting HIV/AIDS into perspective

It looks like 2008 will be a strange year in HIV/AIDS circles. The prospects of controlling the rise of new infections have been dimmed: 2007 was marked by a series of painful setbacks in HIV prevention research, particularly in regard to microbicides, diaphragm and vaccines. Estimates of the scale of the epidemic have been redrawn: the numbers of persons living with HIV/AIDs (most notably, in India) are still in the tens of millions, but found to be substantially lower than previously estimated by the World Health Organization and UNAIDS, raising doubts about these organizations and their statistics. Last year also saw the publication of two high-profile books by Helen Epstein and James Chin that took dead aim at flaws (and some sacred cows) in HIV-related research, policies and programs.

Continuing the dark trend into the New Year, Daniel Halperin has written a New York Times editorial ('Putting a plague in perspective') that gives voice to a very real concern, namely that more mortality and morbidity in developing countries could be reduced if some of the billions of dollars currently devoted to HIV/AIDS in developing countries were spent on other things, such as clean water provision, nutrition or less fashionable (but no less serious) diseases. The pendulum seems to be swinging: since the beginning of the epidemic there have been continuous and passionate calls for greater financial resources to fight against HIV/AIDS from researchers, activists and policy-makers. And their calls have gradually been answered, to the extent that there is now talk of HIV/AIDS being an industry in itself, with its own big agencies (like UNAIDS) and big programs (like PEPFAR and the Global Fund) and big conferences (like CROI and the World AIDS Conferences). But now it looks like a new zeitgeist has arrived, where HIV/AIDS is starting to be viewed as one important global health priority among others. A big killer, yes, but no longer the king of the jungle.

There is an important truth in Halperin's perspective. The struggle against HIV/AIDS should be embedded within a larger political and ethical struggle to raise the health and well-being of populations in developing countries generally. Millions of people continue to live their lives in absolute poverty, millions of people die annually of preventable and treatable diseases, and the gulf between the affluent and the poorer nations is widening. The point of 'putting the plague in perspective' is not to downplay the significance of HIV/AIDS as a worldwide public health problem, but to expose global inequality and injustice, and to develop effective research, policies and programs engaging with the most pressing needs of communities.

But at this point, a skeptic may wonder. Will this expanded vision sell? How many funders be interested in combatting (very unsexy) diarrhea in Tanzania? Where are the activist groups for leishmaniasis, schistosomiasis and onchocerciasis? Can we imagine the US Congress (or the European Union, for that matter) approving billions to something so mundane as water improvement in Malawi or combatting deforestation in the Congo? And what, ultimately, is the difference between what Halperin is saying and those in development circles have been trying to do for decades, and which has hardly been a glowing success in Africa? From this skeptical perspective, 'putting the plague in perspective' is like going from the frying pan to the fire: if you think HIV/AIDS is bad, wait until you see the larger picture of long-standing and intractable problems.

Maybe there is a way of putting the HIV/AIDS epidemic in proper perspective without falling into paralyzing skepticism. The year is young ...