Applying the paradox of prevention: eradicate HIV

The “war on drugs” was proclaimed by the United States in the 1970s. The use of illicit drugs is dangerous and ought always to be discouraged or reduced. No responsible parent of politician would think otherwise. But this “war” concentrated on the reduction of supply, without any coherent domestic effort to minimise demand or reduce harm.

Successive administrations have devoted billions of dollars to futile attempts to eradicate the feedstock and supply of various forms of narcotic drugs - from opium poppies to cocaine. Notwithstanding its position as the world’s greatest consumer of illicit drugs, the United States maintained an official position of “zero tolerance”. It was therefore impossible for the government to condone any policy shift that might be seen as being “soft on drugs”. Zero tolerance of drugs meant high tolerance of HIV and AIDS.

The war on drugs is comparatively recent; the “war on sex” has very ancient roots. The Catholic Church is its institutional vanguard, but the values that underpin it are shared by fundamentalist Islam and evangelical Protestantism. When AIDS emerged, the hierarchy of the Catholic Church immediately realised that the use of condoms to prevent HIV transmission would subvert its opposition to the use of condoms for contraception.

For over two decades, the UN and its specialised agencies have been a major battleground for these brawls. The foundation of UNAIDS in 1996 gave some hope that the balance would tip in favour of large-scale, effective international HIV prevention policies. Yet these hopes were fulfilled more by rhetoric than in practice. This is hardly surprising. The UN and its agencies are, in the end, creatures of and subject to the political forces exercised by and through its member states and largest donors. Throughout the 1990s, the United States, the Vatican and its ideological allies pursued their wars on drugs and sex through the UN.

As bitter as this split was, it at least had the merit of being obvious. The lines between the opposing points of view were clearly drawn. Over time, the consequences of not providing condoms to prevent transmission became apparent when judged against the results in those countries where they were widely distributed.

Despite the “war on drugs”, many countries embraced harm-reduction policies and adopted needle and syringe exchange programs to contain HIV infection among injecting drug users. Gradually, the accumulation of scientific evidence in support of effective prevention began to wear away at least the intellectual foundations of these misbegotten wars. Nevertheless, religious and ideological opposition to behavioural prevention has not abated.

In the last decade, however, behavioural prevention has also been increasingly discounted from a more unexpected direction - from sections of the scientific and medical establishment. In 1996, the first highly effective AIDS drugs were introduced. Since then, a new conventional wisdom has emerged within some elements of the medical and scientific community that discounts prevention as either achievable or practical.

This school of thought has been greatly influenced by the development of very effective new anti-retroviral treatments. Over these ten years, medical science has brought to the market therapies that have greatly reduced the viral levels of HIV-positive people, significantly delayed the onset of AIDS illnesses and generally restored reasonable health and wellbeing to infected people who have access to the treatments.

These new therapies have, of course, been unalloyed good news for those with HIV and a tribute to the excellence of the science and research that created them. Generally, better treatments means that people have an incentive to be tested. Development of these treatments has led many scientists and researchers to conjure the attractive prospect of HIV-AIDS becoming a long-term, manageable condition - perhaps equivalent to diabetes.

Politically, the emergence of effective treatments offered a seemingly happy third way between the protagonists of the great cultural and religious conflicts that marked the early years of the pandemic. While there was bitter and irreconcilable division about how the spread of HIV could or should be prevented, almost everyone agreed on the need for increased funding and support for care and treatment.

Yet this apparently more benign framework created a dangerous new set of perverse incentives that now distort the global management of the HIV pandemic.

Most of the billions of extra dollars devoted to HIV-AIDS in the last decade have been absorbed by drug companies, doctors and the medical system for care and treatment. Over this decade, the results are both spectacular and depressing. In a perverse way, funding care and treatment is contributing to the uncontrolled growth of the pandemic - not in any deliberate way, of course, but that is the effect. If we pay billions to care and treat, we can hardly be surprised if caseloads rise. If very little goes into prevention, we can hardly be shocked that the spread of HIV continues unchecked and uncontrolled.