Monday, August 04, 2008

Backlash against the 'AIDS industry'?

This week sees the launch of the XVII International AIDS Conference in Mexico City. Some of what is going on in the conference can be followed on the website that the Kaiser Family Foundation has set up. But you really have to be there to get the buzz, the celebrities, the infighting, as well as whatever new research results are on offer. Part of my summer reading has included Elizabeth Pisani's The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS, in which she describes the XV International AIDS Conference as follows:

In 2004 Thailand hosted the Fifteenth International AIDS Conference. Once upon a time, these conferences were about science. Nowadays they are about institutional posturing, theatrical activism and money. Lots of money. The Bangkok conference cost US $18.5 million. Nearly 19,000 people rocked up to it, scrummaging for the goodie back-packs given out by pharmaceutical companies. Big pharma paid handsomely to nab the best real estate, the exhibition booths in the center of the main hall. They paid again to get their booths dressed to impress, with cappucino bars, and indoor waterfall and larger-than-life photos of gleaming Western labs and grateful African children. Conference goers could admire a fabulous selection of ball gowns by Brazilian designer Adriana Bertini, all made of condoms. They could gawp at dancing elephants and Puppets against AIDS. Delegates paid around US $1000 each to attend this jamboree.

In the bad old days, the complaint was that not enough was being spent on HIV/AIDS: it was a disease of gay men and junkies, and no one wanted to touch it. The newer complaints are that too much is being spent on HIV/AIDS (relative to other serious health-related conditions) or that too much is being wastefully spent on wrongheaded approaches to the epidemic. Why so much spending on HIV/AIDS and so little for maternal and child health? Why was the importance of partner reduction neglected amid fruitless battles between those (liberals) promoting condoms and those (conservatives) promoting abstinence? To the extent that these complaints are true, these shortcomings would constitute a massive ethical failure, not just a public health one.

So while the official slogan of the conference is Universal Action Now, the unofficial buzzword seems to be: backlash. There is talk of a backlash against the struggle against HIV/AIDS. It is not the misfortune of research into new HIV prevention interventions (in microbicides and vaccines) having gone south last year. This does not help, but that is a setback, not a backlash. The backlash starts from the observation that a kind of private-public industrial complex has developed around a single disease to an extent unparelleled in the history of public health, leading to questions about whose interest(s) this burgeoning industry ultimately serves, especially when -- despite the increasing funding of research and programs -- new HIV infections continue apace and only a fraction of those who need AIDS treatment receive it. Even the head of the HIV/AIDS department of the World Health Organization has muddied the waters by stating that a generalized HIV epidemic outside sub-Saharan Africa may be over, which many took as meaning that HIV is a non-issue if you are not gay, a drug user, or African. Against this background, the International AIDS Conference, with its bling and glitter, can act as a lightning rod for skepticism, conspiracy theories, and general ridicule.

On the other hand: HIV has entered human ecology, and is not going to go away anytime soon. Millions of people continue to die of AIDS, and it is incurable. The virus is extremely complex and adaptive. It impacts low-income countries disproportionately. Basic research, epidemiological studies and the implementation of HIV/AIDS programs around the world don't come cheap. Perhaps a way of dealing with the backlash is to advocate for greater funding and human resources devoted to all diseases (including HIV/AIDS) responsible for high levels of preventable morbidity and mortality worldwide, while fighting against the politicization of approaches to prevent sexual transmission of HIV, and practicing vigilance in regard to the role of pharmaceutical companies within the fight against HIV/AIDS. The HIV/AIDS community has to combat the virus as well as its own tendencies. This is going to continue to be messy, but there is no way back.

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