Lots of red earth flying about intellectual honesty and chains rather than networks of transmission. Will these discussions lead to more clarity? [him] hopes so ...
[him] moderator
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Getting the message
Jun 5th 2008
From The Economist print edition
Good news on treatment. Bad news on propaganda
TO EVERY action, there is an equal and opposite reaction. Newton's third law describes life as well as physics. Once it was only AIDS activists—those with the disease, or at high risk of getting it—who criticised the mandarins of the AIDS establishment. Even then, the criticisms mostly boiled down to two things: “you're not acting fast enough,” and “you're not spending enough money.”
Now, insiders, too, are queuing up to put the boot in, accusing the World Health Organisation (WHO) and UNAIDS, in particular, of sloppy methodology, of the selective presentation of data, and of kowtowing to political correctness in a way that has distorted priorities for the treatment and prevention of the disease.
Ironically, this is happening at a time when the desire of the activists—treatment for all—no longer looks like a pious hope. It may take longer than those activists would wish. And the definition Chin, Piaof “all” may not quite be the one in the dictionary. But the treatment of AIDS is steadily improving.
One-third full or two-thirds empty?
The latest news on treatment is contained in a report published by the WHO, UNAIDS and UNICEF, the United Nations children's fund, on June 2nd. It says that, by the end of 2007, about 3m people were receiving anti-AIDS drugs. That is a rise of 1m in a year, and is part of an accelerating trend (see chart).
This number may look woefully small in the face of an epidemic reckoned to infect 33m people, but most doctors agree that the drugs are best reserved for those whose immune systems are most in danger. That is about 10m people around the world. In other words almost a third of those who could benefit are doing so. Moreover, scepticism that the poor would not comply with the strictures of such drug programmes (in particular, the need to take the drugs regularly to prevent the evolution of resistant strains) has proved unfounded. People in poor countries comply as well as those in the rich world do.
Yet the treatment programme itself—or, rather, its financial consequence—is one of the objects of the revisionists' criticism. Writing earlier this year in the British Medical Journal, Roger England of Health Systems Workshop, a health-policy charity, suggested that spending on AIDS is diverting resources from more cost-effective health interventions, and called for the abolition of UNAIDS. Dr England and those who think like him argue that because of the single-issue activism that AIDS inspires, it receives a quarter of global health aid even though it causes only 5% of the burden of disease in poor and middle-income countries. They also claim that earmarking money in this way makes it harder to strengthen the health systems of those countries. Dr England summed up his criticism thus: “The global HIV industry is too big and out of control. We have created a monster with too many vested interests and reputations at stake.”
The industry's response is that a lot of the money does indeed go into medical infrastructure. A rising tide, as the saying goes, lifts all boats. That is particularly true of money directed through the Global Fund, which deals not only with AIDS, but also with tuberculosis (which kills many of those whose immune systems have been destroyed by AIDS) and malaria (which may kill more people than AIDS does). The World Bank, too, recognises the need to build medical infrastructure. Its latest policy document on the subject, published in May, also emphasises the link between treating AIDS and tuberculosis.
However, there is no plausible rejoinder to another part of the critics' observation, which is that the treatment programme is an open-ended financial commitment. Since the drugs only control AIDS, but do not cure it, they have to be taken indefinitely. Indeed, the WHO report acknowledges that 2.5m people became infected last year. At the moment, those new infections are almost balanced by 2.1m deaths. But as more people are treated, the death rate will fall. Bearing all this in mind Mead Over, of the Centre for Global Development, a think-tank in Washington, DC, calculates that American-financed spending on HIV treatment could soar to $12 billion a year by 2016, up from about $2 billion today. That amount would represent over half of America's total foreign-aid budget for all causes.
Dr England is not the only critic of the acronym-ridden world of AIDS to make his opinions known recently. Elizabeth Pisani, a journalist turned epidemiologist who worked for UNAIDS, spilled her account of spin, waste and denial in “The Wisdom of Whores”, published last month (and reviewed by The Economist on May 3rd). Meanwhile Jim Chin, formerly an epidemiologist at the WHO, has given a more scientific account of the story in a monograph published by the International Policy Network, in London.
Both level two main accusations. First, that the agencies spent many years overcounting the number of cases. Second, that for political reasons they have failed to match their prevention policies to the epidemiological data, and have thus wasted money preaching to the wrong people.
Dr Pisani cheerfully admits to being a doctor of the spin variety herself—she refers to the process as “beating up the news”. She absolves UNAIDS's researchers of any blame. They did their best to collect true numbers in difficult circumstances and with little money. But so as to rack the world's conscience, she wrote reports that put the worst possible complexion on those numbers. When new methods came in a few years ago, the stated size of the epidemic shrank sharply and it became apparent that the annual rate of new infections had peaked in the late 1990s.
Jaw jaw and war war
Every war has its propagandists and the money was for a decent cause. So a little forgiveness may be in order. But the second charge, concerning prevention, is harder to excuse. It has been known for years that HIV is hard to pass on during normal heterosexual intercourse. Only one copulation in 500-1,000 with an infected individual will do so. The risk comes with certain behaviour (anal intercourse, which risks tearing the lining of the gut; and injecting drugs using dirty needles), certain professions (prostitutes of both sexes) and certain ways of life (multiple, simultaneous lovers, rather than serial polygamy). Aiming propaganda at heterosexual teenagers is (outside the special case of Africa) a waste of money. It is, however, often an easier course than tackling drugs, whores and buggery, which many politicians would prefer to pretend have no place in their countries.
Both Dr Chin and Dr Pisani are hard on what they think was a refusal to see Africa as a special case. For years, the continent was, instead, taken as an awful warning of what might happen elsewhere. Both suggest that the disease is severe in Africa not just because this is where it started, but also because many Africans (of both sexes) have multiple, simultaneous lovers. There are married sugar-daddies with teenage girlfriends; lorry drivers and mine workers, who spend weeks or months away from home; wives whose husbands spend weeks or months away from home in lorries and mines. Africans do not have more lovers than other people in the course of their lives, but they do tend to have more at the same time. That creates networks, rather than chains, of transmission, making it easier for HIV to spread. A politically correct refusal to offend by stating that this makes a difference meant, once again, that efforts elsewhere were aimed at preventing a heterosexual epidemic that was never going to happen.
That is not, of course, quite how the WHO sees things. As Kevin De Cock, its head of AIDS, points out, if donors had been more willing to put money into the unglamorous business of counting the infected, rather than the headline-grabbing activities of treatment and prevention, then the true numbers may have emerged sooner. He also says that the uniqueness of the African epidemic has been recognised for quite a long time. Transgenerational transmission of the sugar-daddy variety, for example, was a big topic of discussion at the Durban AIDS conference eight years ago. Moreover, prevention efforts in Asia have concentrated on commercial sex almost from the beginning, even if the squeamish issue of homosexuality has taken longer to confront.
There is, nevertheless, likely to be a lot of flying mud at the next AIDS conference, in Mexico in August. Dr England's point will no doubt lead to demands for yet more money, so that all diseases may benefit as much as AIDS has. Dr Over's will raise an old spectre, one that also goes back to Durban, of the division of the spoils between treatment and prevention. At the moment, treatment has the upper hand, but prevention is becoming fashionable again—it was, for example, emphasised in the World Bank policy document. Dr Chin's and Dr Pisani's criticisms will be dismissed with an embarrassed shrug as old news from people who have books to sell, even as any changes in prevention policy resulting from such criticism are scrutinised for political incorrectness. For you may be sure that throughout it all, the thought-police will be watching for any deviation from the activists' agenda.
http://www.economist.com/science/displaystory.cfm?story_id=11487365
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The Aid epidemic
By Andrew Jack
Published: June 7 2008 03:00 | Last updated: June 7 2008 03:00
When East Timor gained independence from Indonesia in 2002, the US administration showed its support by pledging a $2m "Christening present" earmarked for the most fashionable cause of the period: an HIV prevention programme. The first problem was that there was no Aids problem in East Timor: only seven people in the entire country at the time had tested HIV positive. The second was that the money could have been far better spent on other urgent health needs to save thousands of lives.
Elizabeth Pisani, a journalist turned epidemiologist, was caught in the middle. When her employer, Family Health International, won the contract to spend the funding, she joked that they should use it to round up all the Timorese prostitutes and send them to Harvard.
In her highly readable book, The Wisdom of Whores , Pisani explains that a survey was conducted of those at risk, confirming how modest a threat HIV was. A local office was kitted out, and all administrative overheads were paid. At the end of that, says Pisani, there was still plenty of money left. She hoped that substantial spare change could go to more urgent health needs, such as immunisation. But the local US ambassador insisted on channelling it into high-priced US antiretroviral drugs for a local clinic run by a fellow American, where just a single patient had Aids. "I believe I will be judged by how I deal with people who fall into my path," he said, defying evidence and argument alike.
The incident is one of many described with self-deprecating humour and self-flagellating criticism in Pisani's book, the best in a recent spate of polemics on Aids.
Her thesis is that there is too much ideology and money in the spiralling "Aids industry" - she counts herself among the "whores" who sold their expertise to donors ever more willing to fund HIV work. Her atonement is this book, which describes the internal workings and failings of a system that had the "professional beggars" of the United Nations agencies piling into the "sugar bowl" of funding - even the Food & Agriculture Organisation came up with an initiative on fisheries and Aids.
Pisani joined the United Nations Joint Programme on HIV/Aids (UNAIDS) in Geneva in 1996, when she wrote early guideline documents and assessments of HIV single-handedly. She participated in a process that she says helped raise funds by extrapolating wildly from limited data to exaggerate the extent of the problem. The material warned of the epidemic's spread to the general population across the globe rather than focusing more accurately on smaller endangered sub-groups: those involved in high-risk sexual behaviour or injecting drugs.
By 2006, the annual UNAIDS' report that Pisani originally compiled on her own had grown into a mammoth undertaking - over six months, six writers worked on the document, which ran to 640 pages and cost more than $1.3m to produce, she says. After that year's International Aids Conference in Toronto, however, many of the delegates ditched it wholesale at the airport when, at 2.1kg, it pushed attendees' luggage over their weight restrictions.
Pisani's messages are timely, as the UN-backed Global Fund to fight Aids, TB and malaria (the GF "ATM" as her friends dubbed it) piles up contributions from donor nations of more than $12bn, ahead of the UN's latest high level meeting on Aids in New York next week. Meanwhile the US presidential candidates are pledging to treble the President's Emergency Plan for Aids Relief (Pepfar), created by George W. Bush, to $50bn over the next five years. And the UN's latest estimate in May suggested that of the more than 9m people around the world who need antiretroviral therapy, still only a third were receiving it.
Wisdom of Whores argues that the US imposed wrong-headed ideology: it opposed needle-exchange programmes for drug addicts, for which there is clear supporting evidence, while it stressed abstinence before marriage, for which there is almost none. Still more sensitively, she suggests that HIV activists do not necessarily make the best outreach workers or decision-makers on the disease just because they are infected. She also argues that some of the most effective HIV control programmes have been implemented by tough regimes not overly concerned about human rights such as Thailand and Iran - to which she could have added Cuba and even Uganda.
Pisani believes Aids agencies often don't spend their money where it is most needed, partly because in democracies it's easier to win political and public support for HIV work affecting "innocent women and babies". So large sums are spent on programmes to educate the general population, when they should target more stigmatised but exposed groups: commercial sex workers, drug users and gay men. In Africa, where Aids has - uniquely - spread widely in the general heterosexual population, it is primarily the result of "concurrent" long-term sexual partnerships. Yet far more funding on the continent has gone into treatment or to programmes tackling "poverty and gender inequality", only indirectly linked to the cause of infection.
Such conclusions are not entirely new. James Chin, a US professor of epidemiology, last year argued that political correctness had long prevailed over facts. In his more academic book, The Aids Pandemic , he cites evidence of - and a widespread refusal to discuss - the likely original spread of HIV to the US from Zaire via Haiti, which furnished many expatriates after the Belgians were thrown out of their former African colony in 1960. He also criticises a double standard in analysing the cause of infection: high HIV prevalence in sub-Saharan Africa and US African-American populations is frequently attributed to poverty, discrimination and lack of access to healthcare; when it occurs in gay men, it is described instead as the result of high risk sexual behaviour.
He provides strong-stomached readers with a primer in epidemiology - and claims that such knowledge is sorely lacking in many who pontificate on Aids, including some within and around UNAIDS. He accuses these workers of overestimating the extent of the epidemic or taking a "ride to glory on a downslope" in claiming credit for helping bring about a decline in infection that was already under way. Chin's scepticism of official forecasts has since been partially justified, most notably since India's substantially reduced HIV estimates were announced last year.
Pisani's views, like those of Chin, are trenchantly expressed but still not universally accepted. While she is right that HIV infection is caused by "sex and drugs", most of her own experience and cited examples are from Asia. Many specialists argue that violence, poverty and cultural factors often drive young women into early multiple partnerships, and that these are the issues that must be addressed to limit the spread of Aids, especially in Africa.
Her book could also be subtitled "The Wisdom of Hindsight", given the fast evolving understanding and experience in dealing with Aids even since the start of this decade. In 2003, she might have been justified in re-ascribing the name Pepfar as "the Purchasing Expensive Pharmaceuticals from American Retailers", for instance. But that was when the programme was beginning, before rising volumes, alternative suppliers and the emergence of new regulatory systems and quality controls, shifted orders towards low-cost local drug manufacturers.
As Helen Epstein, a biologist turned journalist, describes in her well-written The Invisible Cure , there is now widespread consensus on the significance of concurrent partnerships to higher HIV prevalence in Africa. But it has only emerged after a decade of fierce debate and research between scientists and ideologues. She also berates UNAIDS for waiting too long before publicly advocating the need for "partner reduction" programmes, arguing that its original analysis on why Uganda's "zero-grazing" approach to fidelity was historically so successful in fighting infection was flawed.
It is regrettable that she does not go further in exploring the details and nuances of Uganda's early successful efforts under President Yoweri Museveni in the late 1980s, when HIV rates were cut by promoting fidelity. They sent out the message that infection was everyone's problem - but they also required a substantial degree of social pressure and even coercion to work.
Epstein argues that the approach was undermined by international health experts. Many believed the programme was too chaotic to be convincing or classifiable. Efforts were further weakened by a more recent "follow the money" switch to abstinence-only programmes promoted by the US. Revealingly, she also cites one condom promotion expert who belatedly concedes that for too long he and many other specialists dismissed fidelity programmes - though not abstinence - because "if they were promoted by the Christian right, they must be wrong".
She rightly attacks the gravy train of foreign non-governmental organisations that, in their desperation to win donor money, have sometimes piggybacked on to the initiatives and hard work of local community groups already helping HIV patients and orphans. By offering nominal "technical assistance" and co-operation, they then lay claim in their reports to be "supporting" people who are actually already clients of local groups (though not previously always picked up in official statistics).
All three authors rightly stress the need for greater focus on "behavioural change" programmes to change high-risk practices. But they have less to offer on what precisely does work and how to expand these practices to bring down the rate of new HIV infections. Epstein's "invisible cure" is a semi-articulated plea for the vague buzzwords that the others scorn: women's rights, economic empowerment, community solidarity. Aside from the anecdotal history of Uganda's previous approach, she cites few latter-day successes beyond a single microfinance project designed to help local women boost esteem and economic independence.
The reality is that changing human behaviour to prevent infection is proving far more difficult than treating those with HIV - just as spending money has proved far easier than showing that it has been well spent. That should not be a pretext to reduce funding but to provoke much broader experimentation, scrutiny and debate on its use. For the general reader trying to understand what has gone wrong to date, Pisani is the best place to start.
Andrew Jack is the FT's pharmaceuticals correspondent
http://www.ft.com/cms/s/e5903bf0-342c-11dd-869b-0000779fd2ac,dwp_uuid=ebe33f66-57aa-11dc-8c65-0000779fd2ac,print=yes.html
