Applying the paradox of prevention: eradicate HIV

This situation is dangerously dynamic and inherently unstable. It is based on assumptions that fail even the most elementary critical scrutiny. The idea that new and effective treatments for HIV will somehow contain the pandemic is wrong, yet the new consensus, backed by billions of donor dollars, creates the illusion that the pandemic is being contained. This might be comforting, but it remains an illusion unsupported by evidence or logic. If we want HIV-AIDS prevention to work, we will have to pay for it, and do it properly in the both the developing and developed worlds.

The present global caseload is 40 million. It is growing at a conservatively estimated rate of four million cases, or 10 per cent, each year. The sheer size of this caseload poses new forms of general health and financial risks. It is increasingly clear that the world cannot afford the real costs of treating even the present caseload, the sheer size of which is transforming the nature of the threat it poses, with immense new costs on national economies and the international system.

The costs of providing anti-retroviral therapies to even a significant proportion of a global caseload that may number 80 million people within a decade are staggering, and have not yet fully been assessed by UNAIDS’ actuarial calculations.

Assuming, conservatively, that each course of therapy costs $US1,000 per person per year, the cost quickly reaches into the billions of dollars even before accounting for the expanded human and capital infrastructure required to deliver it, or the opportunity costs involved in treating HIV-AIDS at the expense of other priorities. Notwithstanding the good intentions of the UN, the harsh political and economic reality is that these costs are beyond the capacities of governments and donors to fund without diverting resources from other critical development areas.

A large and growing caseload also increases the threat that the HIV virus will both increase its resistance to drug therapies and facilitate the spread of new strains of dangerous pathogens, especially highly drug resistant tuberculosis.

By definition, HIV prevention must be directed not where the problem is, but where it is not - at younger, sexually active people and those most likely to experiment with injecting drugs (also most likely to be young). They are unlikely to visit clinics and hospitals, but they can be reached in schools, malls, workplaces, sporting and entertainment venues, and through television, radio, films, phones and the Internet.

Young people at greatest risk of infection won’t be found in churches, synagogues, mosques and temples, but in places where they can have sex and even do drugs. Many young people hang out in cyberspace. To work, HIV prevention messages must be delivered to young people where they are, in ways that make sense to them. Above all, prevention campaigns work best when they are stripped of moral judgments, and overt editorialising about virtue and social improvement.

What is required is a considered economic case for the primacy and viability of prevention. The focus of this must be this region, where a second HIV pandemic is just beginning. Prevention strategies must be the key priority to avoid a repeat of the African catastrophe.

The basic economic structure of health systems must be reconfigured to create incentives every bit as attractive as those that already exist in the system to create care, treatment and research. We accept that the surest way to manage global warming is to create and manipulate economic incentives, costs and prices. This is surely what must be done in relation to the future control of HIV.

If we can provide the right incentives and rewards, and couple them with public health messages that make sense to the most vulnerable groups of young people, the spread of HIV will be controlled far more effectively than any punishment, prohibition, injunction, fatwa or prayer has been able to. When it comes to controlling and managing HIV, the lesson from the millions of a lost generation who died prematurely and painfully is that stern gods are less than useless.