Good news on AIDS in Africa

Each year, the international AIDS establishment makes something of a strategic choice: Remind the world of the severity of the epidemic, how much more needs to be done, and how we are failing the world’s most vulnerable; Or, highlight what’s working, demonstrate that the substantial resources invested are making a difference, and that things are generally getting better. This year, they’ve clearly taken the latter approach, and indeed, there is much to celebrate.

In preparation for World AIDS Day (December 1), UNAIDS has released its annual report, which reports some promising statistics:

In South Africa — the country with the largest number of infections in the world, and where for years, a woefully inadequate response was arguably responsible for a substantial rise in deaths and orphaned children — a full 95% of HIV positive pregnant women are now receiving highly effective antiretrovirals for preventing transmission to newborn children.

New HIV infections in sub-Saharan Africa are down by more than 26% since 1997; and in South Africa, new infections dropped by one-third between 2001 and 2009.

Between 2009 and 2010, ARV coverage rose by 20% in Africa.

The report details some modeling exercises that demonstrate the important impact of various prevention and treatment interventions. Undoubtedly, social scientists will weigh in over the next several months/years to assess the robustness of those claims, but whatever the cause, if these epidemiological trends are accurately portrayed, this is great news.

Happy Birthday HIV/AIDS

A series of “happy birthday AIDS” articles have been appearing in various news outlets this week, including the New York Times and a piece by Anthony Fauci in the Washington Post. It was thirty years ago when health professionals in New York and California identified several gay men as suffering from rare cancers found only among people with severely compromised immune systems. Ironically, HIV is much older than 30, and yet it would not be until a few years after 1981 when HIV would be conclusively identified as the culprit for those cancers… But I suppose the emotional panic associated with those cases can be usefully remembered as the start of the AIDS crisis. And like at so many other periods in the epidemic’s history, concerned activists have successfully used dates and history as a framing device to garner additional resources and attention.

Reading these stories brings back vivid memories: Growing up in New York at the time, one could not be certain where, how, and from whom you might contract this deadly disease. Teachers urged calm and explained how we could protect ourselves, even as they were not yet confident about the facts they were presenting. But as frightening as it all was, I think most of us assumed that it would pass. I definitely would not have guessed how the spread of HIV would reach such global proportions over the next few decades, and I surely imagined that in 30 years, we would have both a vaccine and a cure. And of course, today, we have neither.

While it has been a painful history, with tens of millions killed in the wake of the pandemic, it does feel as though the tide is finally turning. Infection rates are coming down in many countries, the majority of people in need of treatment are on it, at radically reduced drug costs as compared with several years ago, and even the stigma of being infected is not what it once was. In South Africa, almost 12 million people were tested for HIV last year, a fact that would have been unthinkable a few years ago.

For every favorable fact, one can find a compelling counter-point – stigma is still bad in some places, new infections outpace treatment coverage, many are not receiving the treatment they need, and current treatment levels are threatened by shifts in global and domestic spending priorities in the wake of global economic crises. And yet, the simple reality is that people around the world acted to arrest what could have become a much, much worse source of human destruction, and given the complicated biological properties of HIV, this is a remarkable achievement.

Not surprisingly, this week there have been calls to redouble efforts to find a cure – for example from the director of the International AIDS Society. And Tina Rosenberg wrote this week about the incredible case of a man whose HIV was no longer detectable following a stem-cell transplant, also hinting at the possibility of finding a cure. Incidentally, it was Rosenberg’s article on the incredible Brazilian response to AIDS that helped spark my interest in the politics of AIDS, so I am always keen to hear what she finds is a promising new development.

Next week, a “high level” meeting sponsored by UNAIDS will be held in New York City. When I attended a UNAIDS workshop back in April, a few participants wondered aloud how many truly “high level” dignitaries would show up given the range of crises and more politically salient priorities on various agendas. While it is understandable that political leaders would turn their attention to other issues, it would be a shame if the incredible opportunities to pursue radical reductions in prevention – for example through reduced viral loads from combination drug therapies – and yes maybe even a cure or vaccine, were wasted. I am not sure that the “30th anniversary” metaphor will carry much weight, but the history of the epidemic has revealed an incredible well of creativity for capturing the imagination and generosity of others, and perhaps this will work yet again.

AIDS Study Marks Prevention Breakthrough With Antiretroviral Drugs – WSJ.com

AIDS Study Marks Prevention Breakthrough With Antiretroviral Drugs – WSJ.com. This is very exciting news — for a long time, AIDS activists made the claim that offering treatment to people who are HIV-positive was a good strategy for prevention, because without access to treatment, why would anyone get tested? And if you didn’t know your HIV status, you were much less likely to practice safe sex, etc. While this was and is plausible, I’ve never seen this hypothesis tested.

However, the recent medical study demonstrates conclusively, what medical professionals have been thinking/hoping for some time now — that ARVs reduce infectiousness. In the study cited, it reduced transmission among heterosexual couples by 96 percent! It’s not a vaccine, but it certainly implies that treatment will be critical for prevention. When world leaders get together for the high level UN meeting on AIDS in early June, no one will be able to credibly propose switching AIDS-related budgets away from treatment in favor of prevention. Perhaps this link helps to explain why we are beginning to see infection rates fall in several African countries — as treatment access has greatly expanded in recent years.

Can HIV prevention benefit from social media in Africa?

Today, UNAIDS convened a meeting in South Africa to discuss possibilities for leveraging social media/facebook, etc. for renewing the fight against AIDS. In the wake of the Arab spring, and the rising penetration of mobile technology and the internet in Africa, certainly, it’s worth a try. (Indeed, one of the great hopes of the Uwezo project in East Africa I am currently studying is that social media will help spark positive citizen action.) But I think we need to be cautious before jumping to the conclusion that the power of facebook can translate easily to every development challenge. In the case of HIV prevention, it’s still not clear which messages actually work for behavior change, or if young people, or any people, will be moved by such posts in a manner that’s different from the signs they see everywhere, the commercials on tv, the radio, etc. People couldn’t plan a political revolution out in the open and in schools, and protests required tight coordination of individual actions, so social media had much to offer. Perhaps in the area of HIV prevention there could be substantial benefits if people join groups where others pledge to practice safe sex and/or where members of a social network provide clear and accurate information, respond to questions about prevention methods, etc. But, unfortunately, those same networks are routinely used for the spread of false information, and help to facilitate sexual contacts that may increase the risk of greater spread.

Too many HIV prevention campaigns have been launched based on instinct without much in the way of solid research, and I hope that part of the UNAIDS approach to this new terrain will be to promote such investigations. The Gates foundation has only recently begun to invest in social science research for global health and this would be a great area for new studies.

Global governance of hiv, health

The UNAIDS/IAS workshop concluded yesterday. The most interesting aspect of the day’s session was the consideration of the “global governance” of HIV, which is the configuration of international institutions and actors that try to shape policies, services, behaviors, etc. relevant to the control of the epidemic. The speakers were right to point out some concerns about the problem of large institutions not being able to react with the speed necessary for some types of problems, and for what may seem an unbalanced distribution of authority (still dominated by Northern rich countries, as population and target problems are weighted toward the global South.) To be certain, in an increasingly integrated world, we need to think more about what are the right institutions for addressing truly global problems, rather than thinking about them as problems facing an amalgamation of states.

But I still think it’s worth reflecting more on the enormous successes of global governance organizations in responding to and coordinating responses to this pandemic. Activists can, of course, claim that more should have been done. To think that the rich countries were going to support millions of people on life-saving pharmaceutical treatment in Africa and elsewhere while in many cases (well, really just the U.S.), our own domestic politics does not provide much health care to our own citizens… well, that’s a remarkable story.

Am here at the Tokyo airport, and for the most part, all seems pretty normal here — except for the closure of moving walkways, owing to power cuts associated with the fallout of last month’s natural disasters.

Thinking politically about HIV – UNAIDS workshop

I’m looking out onto steamy Bangkok, about to attend the second day of this UNAIDS-sponsored conference on the politics of responding to the AIDS pandemic.
Perhaps the most interesting aspect of the workshop is that it’s being held in the first place! UNAIDS is being fairly explicit that in order to respond effectively to a problem with deep social and political roots, it is necessary to understand country and local  politics. The mantra is, “Know your epidemic, know your politics.” (NB: ee are operating under “Chatham House Rules,” so no attribution is allowed.) I think they’re being pretty bold in being so frank.

A challenge for the workshop is whether the insights from political science scholars can be made usable to political actors in this sector. On the one hand, many actors here (and elsewhere) highlight that politics is an “art,” not amenable to theory or systematic analysis, but on the other, those same people describe patterns they see in their own countries and across the developing world. One commentator said, “naming and shaming” of politicians is a bad strategy; another said it is a good strategy. My view is that the role of political (and other social) scientists is merely to specify the logic of such claims, to examine which seem to be better models of reality, including if they are both true, but just under different conditions.

From a global political perspective, I think one of the great challenges for these actors is whether to describe the response to date as a “success” — look at all of the people on treatment and the degree to which even greater disaster has been averted; or as a “failure” — look at how many new infections occur each day; how drug users, sex workers, and homosexuality are criminalized in so may places, etc. The reality, of course, is a mix, but if one emphasizes too much success, those with the purse strings may say, “problem solved,” let’s move on; if one emphasizes too much failure, it would be tempting to say, ok, after all these years, this is intractable.

The other issue worth mentioning, which I addressed in my  remarks, is the question of political leaders — specifically, do they “lead” or “follow?” I argued that it is worth trying to disentangle the degree to which politicians develop policy preferences based on the characteristics of their constituents, or do they make decisions based on their own individual world views? My research on municipal councilors in the Eastern Cape Province of South Africa finds that for the most part, the individual characteristics of leaders are better predictors of how they think about HIV/AIDS, and this may provide some information about who are likely to be the most committed leaders for what is still a critical problem.

Off to UNAIDS workshop in Bangkok

Tomorrow morning I head off to Bangkok for a two-day workshop on “Thinking Politically About HIV.” Kent Buse from UNAIDS and Dennis Altman from Latrobe university in Australia are bringing together a bunch of political scientists,  policy scholars who write about politics, and several political actors, especially regional directors of UNAIDS, to discuss how various political forces have shaped responses to the epidemic.

I am looking forward to the meeting. Lately, I’ve found myself writing about a lot of dismal stories on African development, and while the AIDS pandemic is still a monumental challenge, there’s actually a great deal of good news, including increases in risk-conscious behavior, greater treatment access, and lowered HIV incidence in many countries. The theme of the workshop is how to harness politics for good, and indeed, political activism has played a very positive role in the global response to AIDS. In the next couple of days, I will try to write about some of the key themes or findings, assuming the discussions are not embargoed. In any case, I’ll post some of my comments… which I need to finish on the plane-ride over… which will attempt to define the ambiguous terms “political will” and “political commitment,” and to share some of my research on municipal councilors in South Africa.

I am not looking forward to the TRIP, however. There are no longer direct flights from New York, so I’ll fly to Tokyo and then connect to Bangkok — I leave at 3pm, arrive close to midnight the next day, wake up and do two days of workshopping, then depart for the airport at around 330am to catch a 6am flight back to Narita, and then back home. I am hoping this trip will be so quick I won’t have time to feel the jetlag…