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NYT on HIV/AIDS crisis: “You cannot mop the floor when the tap is still running on it”

UPDATE 4:10pm 5/11: Bill responds to Gregg Gonsalves’ comment on this post, at the END of the post.

The New York Times ran not one but two articles (edit: make that four) on the global fight against HIV/AIDS last Sunday. As these pieces tragically recount, the international community’s hard won successes against HIV/AIDS are in danger. There is not enough funding to meet the demand for treatment among sick patients in Uganda, and expiring grants, frozen funds, and drug shortages have already or are expected soon to spread to Nigeria, Swaziland, Botswana, Tanzania and Kenya.

The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.

In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.

The reasons given for current and projected shortages include the global recession; a “growing sense” among donors that more lives can be saved more cost-effectively fighting other diseases like malaria or pneumonia; and the disappointing failure of the scientific community to find a cure or vaccine.

The most devastating breakdown of all comes down to failure to prevent enough new infections and a simple, brutal equation:

For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids.

“You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.

UPDATE 4:10pm 4/11 from Bill: I am responding to Gregg Gonsalves’ comment below

Dear Gregg,

First, on the complementarity between treatment and prevention, let’s clear up some things. There is some complementarity, conceivably a lot, but it’s definitely not perfect. Treatment is not necessary and sufficient to do prevention. Prevention will remain a separate goal that needs at least SOME direct attention even if there is a lot of complementarity.

Second, I think to move forward we all have to move out of our defensive positions.

You see my plea for attention to prevention as an attack on treatment programs. There is some justification for this, as I and others have argued, and still would argue, that treatment was used as an excuse by aid and political actors in both the West and Africa to ignore prevention. This is because prevention is both politically and technically more difficult than treatment. But suppose you disagree with this argument – that’s fine. Suppose we all even gave up that argument and said let treatment programs alone. Suppose that none of us blame treatment at all for the inattention to prevention.

Could you then discuss prevention without spending most of your effort defending treatment? Prevention is now not working, as you acknowledge yourself. You are right that there are no obvious new solutions now, but some solution must be found sooner or later – bottom up, top down, or sideways – because you acknowledge that prevention has to work to end the AIDS tragedy. Could everyone involved in AIDS therefore agree there needs to be a new focused conversation and effort on prevention?

Regards, Bill

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14 Comments

  1. I’m so glad that you guys have responded to this article. When I read it, my first thought was, “And what would Easterly say?” Prevention is cheap, effective, more comfortable, but sadly less easy to photograph than treatment. Naturally, NYT barely made passing reference to AIDS prevention ABCs. Do you think AIDS is an easier epidemic for Americans to picture than TB or malaria?

    Posted May 11, 2010 at 3:55 am | Permalink
  2. These articles do illuminate some key facts about the AIDS crisis, but I disagree with a lot of the imagery used to convey these facts. I would hope that the people who wrote “How to write about poor people” would see the stereotypes at play in these articles.

    While I agree that these articles show a lot of the failings of the international community to respond to the crisis, I think they also could be considered a part of the “disaster porn” this blog works to eliminate.

    My full response to these articles is here.

    Posted May 11, 2010 at 10:49 am | Permalink
  3. Caitlin wrote:

    @ Mary,

    The ABC approach has actually not worked in many countries. It would be interesting to begin a dialogue about where the field is on sexual prevention rather than rehash the tired assumption more was spent on treatment because it’s somehow “easier.”

    Posted May 11, 2010 at 10:52 am | Permalink
  4. Gregg Gonsalves wrote:

    Bill,
    Thanks for alerting me to your latest posting. I hope you’re willing to respond to my response!
    First, AIDS treatment and AIDS prevention go hand-in-hand and are mutually reinforcing.
    Without hope, no one would want to get tested–why know if you’re HIV+ if it is simply a death sentence? In fact, we know that the availability of AIDS treatment increases testing rates and knowing one’s status is a key part of HIV prevention.
    Second, no one, I repeat no one has suggested that HIV prevention be ignored in favor of HIV treatment. You continue to repeat this refrain because it sets up a straw man for your larger antipathy towards health care (more on that below).
    Third, HIV prevention is difficult–we’re talking about changing human behavior. If you take a look at the research on HIV prevention you’ll realize EVEN WITH RESOURCES we haven’t been very successful in bringing down infection rates with standard approaches to behavior change. I’d recommend reading Catherine Campbell’s Letting Them Die: Why HIV Prevention Programs Often Fail and taking a good look at the literature. Then, you’ll realize there is a more substantial issue with HIV prevention: we don’t know what works, the research has been weak and most practitioners don’t want to recognize these fundamental facts.
    So, for them, for you, a straw man is set up: HIV prevention doesn’t work because HIV treatment has too much attention, too much money. For people working in HIV, this gives them a free pass on their own failings, for you, it allows you to target HIV treatment as “bad” public health approach.
    I asked you a question after your speech at Yale–it was about your opinion on the right to health. You punted then saying you thought like most economists did on the right to health. Since you wouldn’t elaborate I suggest that means that you do not see health care, and in this context AIDS treatment, as a public good. For economists, AIDS treatment is a private good, like a loaf of bread you consume it alone without any public benefit. Though this is not even true (ART reduces viral load, ART programs increase testing, reduce TB burden), your fundamental problem with ART has absolutely nothing to do with HIV prevention-you don’t think states should be in the business of providing it, full-stop.
    I have worked on trying to improve HIV prevention and have met a lot of resistance–the mantra is we know what works we just need more money. There are a group of HIV prevention reformists who are trying to figure out how to confront the crisis in new infections in our communities, but you are not doing us any good.
    I don’t advocate for AIDS treatment in isolation, I advocate for HIV prevention, health systems strengthening, TB services, the rights of women, migrants, MSM, drug users so they can get the services they need to keep themselves healthy. Again, you make out activists to be single-issue chauvinists–if you talk to any activist, you’ll realize they are covering a wide range of issues in their day to day work.
    Finally, at Yale, you talked about how we needed ground-up activism to reform health and development the world over. That top-down programs that ignore the key role of citizenship and governance, democratic accountability and transparency are bad for poor people the world over.
    Well AIDS has set fire to a worldwide citizens’ movement, a movement that is calling for accountability on HIV, on education, on sanitation, on TB, on health care workers salaries, on fiscal transparency, on gender violence, the conditions of workers in mines, and a long list of things….
    We are the searchers you long for, the activists crying out for governments to do the right thing by their own people and yet you continue to piss all over us, with the disdain of someone who knows better.
    You’ll win Bill. The straight, white men usually do.
    But we won’t give up even in defeat.
    You see we’re not standing in a pool of water, while the tap runs.
    If you were in the room with us, you’d realize that we’re standing in a pool of blood–of the millions who’ve died and are dying now, while the world washes their hands, hoping to rid themselves of the stench of our existence.

    Posted May 11, 2010 at 11:20 am | Permalink
  5. We have failed at prevention and the story glosses over that and calls the proposed biomedical interventions “wildly impractical.” There are groups working to figure out how to replicate and scale-up prevention efforts, and I work for one of them — The Global Health Delivery Project. We’re launching a new online community next week where implementers, researchers and funders can talk share experience about what is and isn’t working.

    check it out http://www.ghdonline.org/hivprevention

    Posted May 11, 2010 at 12:44 pm | Permalink
  6. Caitlin wrote:

    Hi Bill,

    “Could everyone involved in AIDS therefore agree there needs to be a new focused conversation and effort on prevention?”

    As I think I mentioned before on this blog, many people working in HIV and AIDS have called for a renewed focus on prevention. And again, if you’re interested in actually speaking with some of these people I’d be happy to recommend some names.

    Sincerely,
    Caitlin

    Posted May 12, 2010 at 11:00 am | Permalink
  7. Jeff Barnes wrote:

    I agree with Greg about HIV treatment and prevention being reinforcing and I disagree with Bill about the supposed neglect of HIVprevention. More to the point of the NY Times articles, what I find objectionable is the unstated assumption that it is incumbent on the US and other developed nations to be the sole source of financing for the HIV treatment entitlement in perpetuity. Why isn’t the NY Times asking the Ugandan government to do more to allocate its resources to expand and maintain treatment programs? I think Andrew Mwenda could point out areas in the Ugandan government budget that could be redirected to AIDS treatment.

    Posted May 12, 2010 at 1:08 pm | Permalink
  8. Miriam wrote:

    I also agree with Gregg, Caitlin, Jeff and others – when you write “When will advocates wake up? AIDS Treatment Only will always be a losing battle,” you are creating a fictional opponent, which is entertaining but unhelpful. I have never met or read of an “AIDS treatment only” activist, and Gregg is certainly not one.

    I am bemused by the idea that the ongoing epidemic means that treatment (or PEPFAR, or scale-up, depending on whom you read) has failed. The goal of treatment was never to stop the AIDS epidemic, although I echo those who have noted that treatment does avert some new infections (by lowering viral load & infectivity among those on ART, by preventing mother-to-child transmission, by encouraging testing, etc). The goal of treatment was and is to prevent the suffering and death of millions who are already infected and the accompanying devastation of communities and economies. Preventing these infections in the first place would, of course, be preferable – but effective prevention strategies are currently few and far between.

    As I noted earlier (here: http://aidwatchers.com/2010/02/debates-on-losing-the-aids-war/#comment-8902), pitting prevention against treatment may entertain the commentariat, but is not likely to achieve public health gains. We need both, which is why your concern about the lack of effective prevention strategies is echoed by so many of us working in this field.

    Posted May 12, 2010 at 4:59 pm | Permalink
  9. Robert Tulip wrote:

    Disability Adjusted Life Years provide an evidence based criterion to assess health sector investments. In an ideal world we would rank investment by impact. The Global Burden of Disease report by WHO -http://www.who.int/healthinfo/global_burden_disease/en/index.html – indicates that sanitation and road safety are effective low cost measures to improve health. Dirty water kills more people than HIV. Unsafe roads are projected to overtake HIV as a global cause of death in 2019, each killing two million people. WHO 2004 DALY global estimate includes diarrhoeal disease 4.8%, HIVAIDS 3.8%, Road Traffic Accidents 2.7%. A tragedy of the HIV/AIDS epidemic is the competition for scarce funds with other causes of ill health that impose even greater burden of disease.

    Posted May 12, 2010 at 9:38 pm | Permalink
  10. Gregg Gonsalves wrote:

    OK. So.
    We want to fix prevention?
    First, we need to admit we have a problem.
    A friend of mine who ran a large HIV prevention program in the USA was sitting with his staff one evening and they tried to figure out how many new infections they’d averted in the major metropolitan area they were based in. The verdict: only several hundred prevented out of thousand of new infections in this city. I think if we did the same thought-experiment in many places, we’d come to similar conclusions.
    Why are we in this state? HIV prevention was colonized early on by psychologists who enshrined a self-help approach, which involved individual and group level counseling. It’s the bread-and-butter of many prevention programs the world over, but it doesn’t work. Until we treat HIV prevention as a public health issue we won’t make progress.
    What does this mean? Well, I don’t have all the answers but we need to start thinking like those who worked on automobile safety, cigarette smoking and gun violence and realize that working at the level of the individual is too far down-stream to have any population level effects.
    Next we need to decriminalize and destigmatize key interventions for HIV prevention: methadone is illegal in Russia, many countries won’t permit needle exchange. condoms have been opposed by the Church and other religious groups. Those promoting HIV prevention need to be taking on governments on these key issues. I frankly haven’t heard anyone but activists raising these issues.
    Then we need to figure out what drives risk. For many people–the fags, junkies and whores–their societal marginalization and outright criminalization makes it difficult to reach them with HIV prevention. Even if you can reach them, that’s still not enough: they may not really prioritize their own health and that of their partners since they have more immediate worries in their day to day life. In the Gates-funded AVAHAN program in India, sex workers were asked what their biggest problem was, and it was violence. AVAHAN had to address violence against sex workers first, or at least simultaneously in order to do prevention. Thus, key human rights issues will need to be confronted as we try to do HIV prevention, otherwise whatever we do won’t work.
    We also need to realize that having information isn’t the same as acting on it; we’ve spent millions on social marketing campaigns to tell people to “use a condom every time” or to reduce the number of partners they have–why do people persist in behavior that puts them at risk even if they know better?
    What else? There are institutions that are fire-starters in terms of HIV/STI/TB risk: the mines in Southern Africa for instance. Talk to anyone who has worked on miner’s health and you’ll realize that HIV, TB, and STI are crossing borders all around Southern Africa unabated. Prisons across the world are also a factory for the spread of HIV and TB and its hard to get permission to do real prevention in this setting.
    Speaking of Southern Africa, South Africa is the rape capital of the world–sexual violence puts many women at risk and we’ve got to address women’s vulnerability if we’re going to reduce new infections among women.
    So, we want to fix prevention?
    There are no easy or simple answers, even biomedical approaches, like circumcision or yes, ART as prevention, need to be part of “prevention combination therapy,” which take on a range of different interventions at the individual, group, community and societal levels.
    But I hear none of this among those criticizing AIDS treatment or even among leaders in HIV prevention. HIV prevention has stagnated, been allowed to flounder and muddle along, with experts, yes, like you Bill, letting the field off the hook, since the focus on treatment is being staged as the biggest obstacle to HIV prevention.
    One of the best ways to address community health is to mobilize communities around their own needs. Helen Epstein talks about this in her book, the Invisible Cure at length and I’ve spoken to Helen about it. The best HIV prevention has been when communities stand up for themselves as gay men did in San Francisco and in New York even before there were HIV prevention programs to speak of, in Uganda in the very first wave of the epidemic there. Real drops in incidence happened when people took matters into their own hands because the response wasn’t mediated through an agency or outsiders, communities felt under threat and acted.
    We can’t recreate the fear that drove these early mobilizations, but as I’ve said to you again and again, AIDS activists have created a world-wide movement, which is as close as we’re going to get. My colleagues in Russia speak out about methadone and needle exchange, but they also speak out about HIV, TB and HCV treatment. My friends in Zambia speak out about the conditions in prisons, the salaries of health workers, but also on HIV and TB treatment. My friends in South Africa, speak out on toilets and sanitation in the townships, gender violence, primary and secondary education, the rights of gays and lesbians but also AIDS and TB treatment.
    So, here I’ve discussed where I see HIV prevention going and where it needs reform, but I think that in the end, we need to do both HIV prevention and treatment. You want to make them separable, but they are Siamese twins joined together in too many places to make pulling them apart safe for either of them. The new shift away from HIV treatment as represented by the Obama budget and portrayed in Don MacNeil’s articles this week isn’t going to “help” HIV prevention. It’s going to return us to the days of hopelessness, when an HIV diagnosis was a death sentence, and knowing your status was only a source of torment.
    The attacks on activists as rent-seekers or single-issue chauvinists also risks just pulling the rug out from underneath community mobilization from Nepal to Botswana, from Bolivia to Ukraine.
    The die has been cast in some ways already. The Obama budget, the shortfall in the Global Fund, the “new conventional wisdom” that AIDS has gotten too much money or has hurt health systems has locked us into a decline in the response to AIDS for the next 3-5 years at least. What is being set up as the next “thing” is an anemic response to global health represented by the Administration’s Global Health Initiative, old sector-wide approaches which see health and development as administrative problems more than anything else (here represented by the International Health Partnership +).
    You know my friends got thrown out of Tanzania last week. They were young people mostly, working for different AIDS organizations across the continent, from Ghana to South Africa, from Uganda to Kenya and they had gone to the African Economic Forum to protest the refusal of their governments to invest in health (not AIDS, health). Rather than take their memo which they had written for the assembled ministers and presidents, the police were called, they were deported and they slept on the floor of the airport before their flights left the next morning. You’ve spoken so eloquently about how democratization and citizenship are critical to development—here are young Africans most under 30 years old, speaking out, unafraid to call out their governments on their messed-up priorities, to highlight official corruption.
    But that era is over now. We’ve worked on the edge for 30 years. Activists by and large don’t work for big NGOs, since donors don’t fund trouble-makers. The current backlash against AIDS is going to wash away what is one of the most potent citizens’ movements across the world. You will say well you didn’t mean to do this, but White Man’s Burden casts activists as powerful special interests, when they are simply young people, fags, junkies, whores, poor people, who found a way to break through the barrier that kept leaders and experts from hearing their voices. In a very perverse way, you’ve given governments the green light to ignore these voices again, to throw them out of discussions (or out of the country!), since they are part of the problem in your analysis. My friend Wan Yan Hai just fled China this past week—activists’ lives are precarious in many ways, they need support not vilification.

    So much of what you say is right-on Bill. I loved your talk at Yale. But somehow we got put in the corral with the enemies of the new ways of thinking you’ve outlined in your talk. It’s a real shame because I do think we are your searchers, your citizens, speaking up, breaking free of old ways of thinking, demanding governments do the right thing.

    Posted May 13, 2010 at 6:53 am | Permalink
  11. Gregg Gonsalves wrote:

    Oh and to Robert Tulip: We are not in an ideal world. Making decisions with calculators alone is a deadly folly.
    As I’ve said here AIDS activists are speaking out on a wide variety of health and development issues. The Treatment Action Campaign in South Africa has spawned groups pushing for educational reform and libraries in every primary school in the country; for proper toilets and sanitation in the townships; for enforcement of laws against sexual and domestic violence among other things.
    We’ve been speaking out on the need to direct priorities towards health and development not the personal enrichment of national leaders.
    We can build an international and national movements on a wide variety of issues by working together, but pitting disease against disease, one area against another, simply sets the battle up as one about scrambling for crumbs from the table of politicians, rather than pushing for a shift in priorities overall.
    We know the US and other governments can find billions when it suits them-the EU just pulled a shitload of money from out of thin air to stablize the Euro and the faltering economies of Greece, Portugal, etc…Yet a few % of that sum and that of the American bailouts would make some of these resource arguments among us moot.

    Posted May 13, 2010 at 7:03 am | Permalink
  12. Miriam wrote:
    Posted May 13, 2010 at 8:29 am | Permalink
  13. Robert Tulip wrote:

    Disturbing comments in the NYT articles:
    “The arrival of AIDS drugs let some go back to old habits. “When you are sick, you are tired, you are impotent,” said George Bitti, 58. “But when you are on the drugs for a certain period, you become strong, you regain your body. And you start going again for sex.””
    “Family members like Ms. Kamukama and her cousin will often share one set of pills, an act of love that leads to disaster. Incomplete treatment means both will probably die, but may first develop drug-resistant AIDS and pass it on.”

    The epidemiology of sharing pills and returning to promiscuity is frightening.

    Posted May 13, 2010 at 9:22 am | Permalink
  14. wow, thank you so much for posting this.

    Posted May 13, 2010 at 10:21 am | Permalink

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  1. […] This post was mentioned on Twitter by @mikegechter's RSS. @mikegechter's RSS said: NYT on HIV/AIDS crisis: “You cannot mop the floor when the tap is still running on it”: The New York Times ran not… http://bit.ly/anHb2M […]

  2. […] Simply giving more money is not an answer. I recommend reading the full New York Times piece and Bill Easterly’s response for further perspective.Living with HIV in Cambodia thanks to ARV medications provided by USAID […]

  3. […] Mead Over at the Center for Global Development writes an excellent counter-piece, taking the line that, while cuts are a setback, to claim that the war is falling apart overstates the success of efforts until now.  He argues that real success would be lower infection rates rather than more people on treatment.  Over’s post should be read in conjunction with Gregg Gonsalve’s comments and Bill Easterley’s rebuttal here. […]

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    The Aid Watch blog is a project of New York University's Development Research Institute (DRI). This blog is principally written by William Easterly, author of "The Elusive Quest for Growth: Economists' Adventures and Misadventures in the Tropics" and "The White Man's Burden: Why the West's Efforts to Aid the Rest Have Done So Much Ill and So Little Good," and Professor of Economics at NYU. It is co-written by Laura Freschi and by occasional guest bloggers. Our work is based on the idea that more aid will reach the poor the more people are watching aid.

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