By Kent Buse and Fiona Samuels
Tomorrow (1 December 2007) marks World AIDS Day - with ‘leadership’ selected as the theme of the global response to the disease for 2008. Throughout history, leadership in the control of sexually transmitted infections (STIs) has often been exercised on the basis of ideological conviction rather than evidence. One of the earliest recorded policies for controlling STIs is found in the Old Testament. It reports that following war on the Midianites, Moses ordered the slaughter of Midianite women "who had known man by lying with him - to prevent a plague among the congregation." Julius Caesar had soldiers with STI symptoms flogged, while Richard III went further yet and hanged any soldiers he led who had "the pox."
In the 1950s and 1960s, Mao and his followers seemed to successfully eliminate STIs from the Chinese population. Policies of mass screening and appropriate antibiotic therapy were combined with the elimination of sex work and the branding of STI elimination as "patriotic action". Political leadership, this potted history would suggest, can be resolute and yet seriously misguided.
Sadly, intellectual leadership has often been equally misplaced. For forty years, up to 1972, scientists abandoned medical ethics in the infamous Tuskegee experiments in which they fastidiously observed and recorded the natural progression of syphilis on illiterate and poor black share croppers while failing to offer available treatment. Scientists can be swayed in their choice of research by political leadership and their sources of funding. Hence, the current over-emphasis on clinical trials, or abstinence as a prevention method, for example, as opposed to research into the structural determinants of HIV.
The record of moral leadership on the control of sexual infections is also marred. The Catholic church's leadership and guidance on the use of condoms, not to mention recent propaganda, such as that from Catholic Archbishop Dom Francisco Chimoio of Maputo, Mozambique, who claimed in an interview on BBC radio that European condoms deliberately contain HIV so as to infect and decimate Africa’s population, has certainly undermined efforts to promote the use of condoms. Consequently, such leadership is arguably directly responsible for a considerable burden of disease and death. The moral compass offered by the Church’s approach to sexual health has been reinforced by the current U.S. Administration. Notwithstanding the irony of the resignation of Randolf Tobias, the former U.S. Director of Foreign Aid, for his use of an escort service while supervising the “Anti-Prostitution Pledge" which restricts recipients of U.S. funds from providing services to sex workers, it is arguably the case that morality-informed leadership actively undermines efforts to curb and reverse the spread of STIs. In the specific case of the U.S. prostitution pledge, it damages efforts to work with highly vulnerable women (and men) to combat the spread of HIV. In other prevention areas, such as among injecting drug users, recourse to so-called morality has often removed the only known effective intervention, that of needle exchange, from the public health arsenal.
Thankfully, some enlightened leadership has emerged for STI control. In recent times, for example, moral leadership has been embodied by Jonathan Mann who is widely credited with placing the control of STIs within a human rights framework. Skilful political leadership witnessed the rise of AIDS up the international development agenda – so that it could no longer be ignored by the UN General Assembly and the G8 – albeit even if these were only rhetorical victories. Progressive political leadership was displayed by a range of individuals and groups who forced the question of intellectual property protection back onto the international trade agenda and won the Doha Ministerial Declaration on the Trade Related Aspects of International Property Rights (TRIPS) Agreement and Public Health in November 2001. This declaration permits member states to make full use of flexibilities to grant compulsory licenses so as to improve access to essential health products – such as generic antiretroviral therapy. A small army of researchers has now produced a vast quantity of evidence on the nature of the epidemic, what works and what doesn’t in controlling it in different contexts, and what is and isn’t cost-effective. Despite this leadership, it would appear that we are still far from curbing the pandemic. What types of leadership do we now need in order to achieve real progress, and to which particular challenges might they best be directed?
We believe that the global response to HIV will require leadership in three critical areas in 2008 and beyond. These include the challenge of moving away from ‘AIDS-exceptionalism;’ rebalancing national prevention-care-treatment responses; and dealing effectively with the poverty, stigma and discrimination which fuels most epidemics.
Exceptionalism. When AIDS first appeared, it was largely accepted that the corresponding response should deviate from standard public health practices regarding infection control, surveillance, testing, and partner notification. Over time, exceptionalism has extended to other realms. Buoyed by special interest groups, AIDS programmes in many countries are now marked by inadequate integration into national planning, budgeting, service delivery and monitoring systems – often attracting a disproportionate share of health spending and often undermining rather than strengthening national health systems. A backlash against AIDS exceptionalism has begun and creative leadership will be required to ease AIDS programmes and spending into more rational patterns.
Prevention-treatment balance. Responses and debates around HIV/AIDS have been conceptualised as residing on a continuum of prevention, care and treatment and impact mitigation. Whilst responses ideally need to take into account all stages of this continuum, the existence of multiple different priorities, interests and funding sources, has often led to one aspect being neglected. The last few years have seen an increasing focus on the provision of Anti-Retrovirals (ARVs). As a result of lobbying, falling ARV prices, support from donors and increasing commitment by governments, ARVs are now becoming increasingly accessible. With the furore that the arrival of ARVs created, there was a tendency to place prevention on the back burner. More recently, also spurred on by the Universal Access commitments, and with increasing knowledge about the effects of and behaviour associated with ARVs, some renewed emphasis on prevention can be seen. Leadership is now required to ensure that prevention remains squarely in the picture as a fundamental component of the continuum. As past experience shows, prevention strategies are complex, longer-term, and are often intricately linked to cultural issues around sexuality and norms. Nevertheless, prevention cannot be neglected, and leadership is needed to navigate the gamut of existing prevention technologies, some more tested and proven than others, and to select the most appropriate strategy(ies) for a given context.
Stigma and discrimination. AIDS-related stigma and discrimination pose one of the greatest challenges to curbing the pandemic. Stigma and discrimination are rooted in shame and fear: shame because of the taboos surrounding the modes of transmission, namely sex and injecting drug use, and fear because of a continued lack of knowledge about the disease. Stigma builds upon and reinforces existing inequalities within societies resulting in social exclusion and further marginalisation and impoverishment of vulnerable groups. HIV stigma also interacts with pre-existing stigmas, and results in discrimination, towards homosexuals, sex workers, injecting drug users, and women. Decreasing AIDS stigma is a vital step in stemming the disease and strong and committed leadership is needed that can create the environment for all to exercise their rights-based choices in relation to sex – which incorporates the right to be safe and the right to consensuality.
More broadly, leadership is needed that can mobilise societies to address the root causes of STIs, which include poverty; sexual violence; and stigma and discrimination. Everyone therefore has some degree of responsibility to demonstrate leadership in the global effort to curb the HIV/AIDS epidemic.
By Kent Buse and Fiona Samuels