Research on the politics of AIDS

To coincide with the International AIDS conference, which is ongoing in Washington, D.C. right now, Dennis Altman and Kent Buse organized and edited a special journal issue entitled, “Thinking Politically About HIV.” Most of the papers were discussed in some form during a workshop I attended in Bangkok last year.

My own chapter examines the extent of substantive representation on infectious diseases in South Africa according to race and gender. Others include an overview of political science research on the epidemic, and various case studies spanning world regions.

Also, perhaps of interest, for those (such as myself) who are not actually attending the conference, the Kaiser Family Foundation is hosting live and archived webcasts of major sessions.

XIX International AIDS Conference (AIDS 2012) Washington D.C. Plenary Session © IAS/Ryan Rayburn –

Nairobi-based accountability for Global Fund

As I contemplate an imminent trip to Kenya in less than two weeks, I was doing a bit of research on government accountability, and stumbled upon an interesting organization — Aidspan — which is, ” an international non-governmental Kenya-based organization whose mission is to reinforce the effectiveness of the Global Fund to Fight AIDS, Tuberculosis and Malaria.” The director recently penned an article about the non-disbursement of round 2 funds, in which he concludes that 20,000 lives were “not saved,” as a result of the bungling. Apparently, he has been closely following all of the grants to Kenya and has identified local and international mis-management, while also highlighting some real improvement in recent years.

In some ongoing work I’ve focused on accountability at the very local level. But in a world in which development is being governed at so many levels, this type of “watchdog” organization seems extremely valuable. In certain circumstances, overly zealous critics can de-legitimize important aid projects by crying foul at every minor wrong turn. But Aidspan seems truly committed to making the Global Fund work, and communicates its concerns both publicly and privately, as appropriate. Clearly some research is needed, but such citizen-based accountability initiatives would seem to be a key ingredient for promoting effective global governance.

While the organization appears to have been founded by a British economist — Bernard Rivers — he decided to base the organization in Kenya, and to develop a Kenyan staff to implement its mission. In the unlikely event that I have some free time in Nairobi, I will try to learn more about their work.


Successful AIDS tax in Zimbabwe

Sometimes it’s easier to assume that everything is worse in Zimbabwe.  A failing kleptocracy, with a president who makes everyone’s short-list of despicable tyrants, Zim always provides ample ammunition for arguments about the superiority of democratic governance for human development.

And yet, the government has had a fairly successful AIDS levy, which the UN reports has helped to close some of the funding gap associated with declining donor support and increased needs. The levy is a 3 percent tax on income, and with some improved political and economic stability in the past year, this is generating several million dollars in income, perhaps about $25 million in 2011.

Generally, I am not one for ear-marked taxes, but in certain cases, such as war and national disasters, the notion of a general solidarity fund is a quite reasonable way to raise revenues. In the case of AIDS, not only does it provide a justification for an extra burden, but it can help to de-stigmatize the disease by making its eradication a national project. To be certain, there have been reports that AIDS funding from donors and from the tax have not all made their way to the people who need treatment or related services. But along these lines, I must say that when I was in Zimbabwe in November 2010, I visited several observed pretty well functioning government clinics.

Of course, my point is not that the general state of affairs in Zimbabwe is much rosier than what we generally hear (see, for example, my review of Godwin’s The Fear), but that good ideas sometimes come from unlikely places; and that one of the reasons that awful regimes don’t collapse as quickly as we think they should is because they sometimes make and implement decent policies.

Stephen Lewis needs to be a bit more cautious about how he treats scientific evidence

I really like and admire Stephen Lewis — the guy has been an enduring, committed, and vocal advocate for global HIV/AIDS for a long time. And I suppose what distinguishes an advocate who really gets things done from academic types, is the degree to which the latter feels compelled to make claims based on evidence and to explain the limitations of  arguments and conclusions. In other words, I admit that much of what has been accomplished on global AIDS would likely not have been the case if every policy decision were rooted in an arduous process of research and analysis rather than on a good measure of instinct and emotion.

But in reading Lewis’ remarks from the recent international conference on AIDS and STI’s, I found myself a bit frustrated. He seems to cherry pick ideas that looked promising and were not rapidly embraced until there was substantial scientific consensus. He writes,

I’m thrilled when I hear animated talk of male circumcision. But I know that we didn’t need to wait for the results of the three studies in Uganda, Kenya, and South Africa. Nothing would have been lost if we’d focused immediately on making circumcision safe and available for informed parents to choose for their male babies; it’s a minor procedure that has been performed for centuries. Instead, during nearly a decade as the evidence piled up that circumcision was a defense against AIDS-evidence provided by experts in the field-we waited and waited and waited, in that self-justifying paralysis of excruciating scientific precision. As we come to this thrilling moment of progress I cannot forget the numbers of lives that might have been saved had we acted sooner.


I’m thrilled with all the talk of “Treatment as Prevention” and how it has suddenly become the mantra of the international AIDS community. But back in 2006, I sat beside Dr. Julio Montaner, about to become President of the International AIDS Society, when he first expounded the proposition at a press briefing at the International AIDS Conference in Toronto. His evidence and argument were rooted in science and common sense in equal measure. But he had to endure scorn and derision, and we had to endure a five-year delay until Treatment as Prevention was definitively authenticated by the National Institutes of Health in Washington. Julio’s theory suddenly became the 96% solution five years later, and it doesn’t-I emphasize-it doesn’t apply only to discordant couples. As we come to this thrilling moment of progress, I cannot forget the numbers of lives that might have been prolonged if we hadn’t waited nearly five years to create the momentum that now propels us.

Ok, with 20/20 hindsight, ideas that seemed right, and turned out to be right, ought to have been embraced earlier. But what about something like microbicides that were the darling of the international AIDS community until the scientific community showed them to be ineffective? Imagine if those had been promoted on a wide scale without evidence? Or imagine if widespread circumcision had been promoted and the evidence showed it to be ineffective?

It’s certainly good rhetoric to blame the “international community” for going too slow on some issues, and when he complains about things like donors reneging on their commitments, he’s dead on. But when he begins to suggest that we should not impatiently wait for good scientific evidence before launching global health problems, he really loses me.

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.

Swaziland on verge of implosion?

When I last wrote about the state of the Swazi economy, the government was scrambling to stay afloat. The situation has continued to deteriorate and the Mail & Guardian reports that a recent IMF mission deems the current crisis has reached a “critical stage.” Although the government recently pulled together enough money to pay government employees this month, next month’s pay checks are in serious jeopardy, and some private companies that rely on government contracts have already begun to lay off workers.

King Mswati continues to blame outsiders for his country’s woes. South Africa offered to provide a R2.4 billion (~$290 million) loan several months ago, but no money has been transferred because Mswati has yet to agree to the conditions of the loan, which include political and economic reforms. Swaziland has thus far refused to a wage cut for government workers as well, which the IMF considers a necessary step.

The financial troubles are exacerbating the challenge of responding to the country’s AIDS pandemic — the world’s worst — and various reports highlight that the country is facing shortages of HIV/AIDS supplies. PEPFAR has provided emergency funds for first-line ARVs, but in a nation where nearly one in four people are HIV-positive, gaps in critical health care will only exacerbate the dire economic situation.

This previously stable, middle-income country is looking more and more like a train about to go off a cliff.

New Research on Governing Infectious Disease in South Africa

How should the response to infectious disease epidemics such as HIV/AIDS, TB, and Malaria be governed? That is, which authorities – ranging from local governments to national governments to global governance institutions –  should be in charge of setting policies, developing budgets, and ultimately serving citizens who need information and resources for prevention and treatment?

This is a question that has too often been answered with polemics, but with little solid research. And yet, as important as good bio-medical knowledge may be for protecting the health of people, so is the mode of implementing such practices, particularly in democratic contexts.

The “old” model of leaving national states 100% in charge, holds little currency these days, and for good reason: in low- and middle-income countries, “the state” is often weak, inefficient, unresponsive to citizens, and especially unable to reach the most vulnerable. As an alternative, a new model has emerged — what can be described as “Polycentric governance.” While this model (in form, but not name) has been advocated as a best practice for addressing public health issues in developing countries, there is good reason to believe that the model contains features that may simultaneously impede efficiency and democratic accountability. The journal Social Science and Medicine recently published the results of my case study of polycentric governance of infectious disease in South Africa, which highlights these limitations.

My study raises more questions than answers for policy and institutional design. It does not recommend a new “optimal” governance model. But it does suggest that much more research needs to be done that takes seriously the motivations of political actors and service providers, whose concerns are not always with the general welfare, but with (often understandably) parochial issues, such as ensuring the next round of funding, or satisfying other constituent or party priorities.

In the country with the largest number of HIV-infected individuals in the world, polycentric governance needs to be re-evaluated as the best solution for providing prevention, treatment, and support.

Gossiping about AIDS

Like many, I am a sucker for the Chicago Public Radio program, This American Life. So when I loaded up the latest episode for my commute home yesterday, I was prepared to be entertained — especially since the show was billed to be about “Gossip.”

This American Life – Gossip

And I did love the show… But only the first few minutes were what I expected (a story about how a man inadvertently spread news about the sex life of his wife’s hairdresser…) The bulk of the program investigated Susan Watkins’ fantastic project studying how people talk about HIV/AIDS and sex in rural Malawi. It is seriously entertaining and informative, highlights all sorts of mistaken premises of longstanding prevention programs (like the idea that people don’t talk about sex or AIDS because she finds that they do all the time), and some of the popular ideas that fuel attitudes, behavior, and transmission of the epidemic. One particularly amusing anecdote is the discussion among men that it’s a better idea to sleep with a “bargirl” because “everyone” knows she sleeps around and has AIDS, and in such cases, there’s no question that you would wear a condom.

Anyway, Watkins’ work is some of the most important social science research on the social determinants of disease, and her approach — of getting ordinary people to keep journals, rather than conducting more artificial surveys — clearly bears a lot of fruit. Information about this breath-taking project are available here.

Amazing: Scientific knowledge translated into South Africa HIV policy

Various scientific studies have recently demonstrated that putting people who are HIV-positive on ARV drugs much earlier will help to extend their lives and to reduce the rates of transmission. All-too-often, that type of discovery fails to be implemented for the people would benefit most. But this week, the UN News Service, IRIN, reports that South Africa is changing its treatment policy to begin treatment when CD4 counts fall below 350, rather than 200.

I have spent a lot of time writing about the political barriers between good science and implemented practice… and this has been quite a longstanding pattern in South Africa. It is certainly encouraging to see progress without such blocks, especially in the country that continues to host the largest number of HIV-positive individuals in the world.


PlusNews Global | SOUTH AFRICA: Govt moves to earlier HIV treatment | South Africa | Care/Treatment – PlusNews | HIV/AIDS (PlusNews).

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.