HIV/AIDS: The case not to treat

September 21, 2006 at 11:20 am (Sarah's Posts)

Let’s make some assumptions about the global community. Let’s say that you’re a developing country with limited resources. You’re working hard to push for the development of your country. So there are many sectors that are fighting for a piece of your national budget.

Let’s also say that you have an HIV epidemic. You don’t have tremendous disease surveillance systems, but you know that HIV prevalence rates in antenatal clinics are about 1%. Consequently, you know that your epidemic has crossed over from those people who engage in high risk behaviors to the general population. The question to you, the policy maker, is what do you do with your limited budget to deal with this epidemic?

There are folks around here who make the argument that, from a public policy perspective, it is better not to treat India’s 4.5 million infected individuals. They argue that adequate treatment is simply not possible in the current Indian context. There are the immediate issues like availability of ARVs and treatment, infrastructure to deliver care, trained personnel to offer counseling and treatment, poor diagnostic services, stigma, and the very real possibility of introducing drug resistant strains of the virus due to poor compliance. Perhaps the most disheartening argument is that the Indian health care system simply is not equipped to deal with long term chronic infections. For most purposes, HIV/AIDS in a chronic disease in the developed world. We have the treatment and care to keep people living with HIV/AIDS healthy for quite a long time after infection at a very high standard of living—a wonderful achievement. But the Indian health care system is built to handle infectious diseases and acute short term care. The financial burden of keeping these 4.5 million people alive, such that they are accessing health care for a very expensive disease for years longer, would drain the small pockets of the health care budget. Perhaps that money needs to be poured, instead, into developing the health care system to deal with long term chronic care. With limited resources, it could be that the money needs to be invested in developing the ability to deliver care at the cost of the individuals who need treatment.

This is deeply neglecting the humanitarian side of HIV care. Just thinking about it makes my stomach turn. Still, it has been striking me lately that the subject of public health policy sometimes necessitates thinking about such cruel balances. I would love to pretend that we live in a world where resources are not a limiting factor. But when I look at the scenes around me every day, I am forced to admit that this is idealistic and that the situation on the ground is stark. There is a horrible synergy between poverty and disease—how do we begin to break that cycle?




  1. Alex Coria said,

    This is exactly why public health advocacy is so important. Pressure on the highest levels of the world’s governing bodies is essential to make sure drug prices come down, vaccines are subsidized and infrastructure is developed. Big pharma only responds to media attention and pressure from governments.

    But once you’ve gotten the buy-in from the highest levels, as we have on many fronts, how do you help countries use funds effectively? Uganda and Myanmar both had Global Fund grants revoked because of corruption and lack of effective use of funds, essentially. So how do you get countries to stand on their own two feet? How do you make aid not a handout, but a help?

    And, moreover, how do you make the decision between giving funds to Myanmar and giving them to India? It’s the same issue Sarah presented here, but on a grander scale – do the Burmese have to die because their government is corrupt? Don’t they have a right to the best we can offer them? Don’t we have an obligation to make medicines available to them?

    So many issues of access…how does one choose?

  2. david egilman said,

    This is an excellent point & is true. This is a result of the US & European know it alls pushing their cultural constructs on others.

    This is why locals need to run their own show.

    David Egilman MD, MPH
    Clinical Associate Professor Of Community Medicine
    Brown University
    8 North Main Street
    Attleboro, Massachusetts 02703
    Office: 508-226-5091
    Fax: 425-699-7033
    Cell: 508-472-2809

  3. msoule said,

    There is an obligation, but there is also the issue of monies going to the wrong places. As you said, Alex, aid becoming handouts which disappear into various illegitemate coffers. The fact is that when Northern (Hemisphere) donors place restrictions on loans, they are often not the right restrictions. So, local groups must be in charge of channeling the funds to the right places. However, when money comes from abroad in large quantities, it is difficult to ensure that all of it does what it needs to do. Which is why it is tempting to say that they need to run their own show. But this goes back to what Sarah is pointing out: what if there isn’t a show to run? It’s all well and good to say that they need to be self-sufficient, but the ground-level realities often show that the resources that are available do not add up to anything that could begin to be self-sufficient. So is it up to us to provide resources? And if we do bring resources, obviously we need some control over how they are used so they are not wasted. But then we bring our skewed, often inappropriate biases into the picture and the terms of care get skewed from what is best in the local scenario.
    A vicious cycle indeed.
    Back to the original post, though. I am going to make a new post in response to Sarah’s original and let the conversation that started about resources and allocating them and how to do it go on here.

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