This is intended for SEA-AIDS but also is being shared with others.
Two items appeared today, which present different pictures of disease
control activities. The first was a statement by the Director of the Pan
American Health Organization (PAHO), discussing the value of direct observation
therapy - short course (DOTS) for monitoring and treating patients with
tuberculosis. The citation in the CDC Daily AIDS Summary (3/25/98)
10 countries -- including Cuba and the United States -- and two territories
in which DOTS was implemented, 76 percent of patients receiving treatment
were cured, as compared to a 30 percent success rate in the 13 countries
that did not use the system." Funding agencies like such talk of success,
based on a biological rationale and evaluation studies, and likely will
provide additional financial assistance for TB control programs to help
in their efforts.
The second item came from an adviser to the UNAIDS Intercountry Team
in West and Central Africa (SEA-AIDS, 3/25/98). Most of you linked to SEA-AIDS
saw this item. The advisor described a regional initiative for "the development of
strategies to reduce risk and vulnerability in the context of sex work."
For those working in public health, such activities are appropriate
since commercial sex workers are an important core group in the transmission
of HIV infection. The UNAIDS advisor goes on to describe the establishment
of a network for bringing together those working in the field, much like
SEA-AIDS. So far so good. Yet where this second item differed from the
first was in the statement, "While this network would initially focus on
health and, in particular, STD/HIV/AIDS-related issues, the vision is a
more multi-sectoral one involving structures concerned with social, economic,
legal and human rights issue. The network could help exchange experience,
create a forum for the development of innovative ideas, facilitate inter-country
activities and advocate for reducing marginalization of those involved
in sex work."
Suddenly, instead of a biologically-oriented intervention initiative
aimed at promoting condom use, HIV testing, and early diagnosis and treatment
of STDS, the intent of the initiative is to move into the broader social
arena where politics and values hold sway.
In the international arena, we increasingly find that money donated
by wealthier societies is becoming scarce, as new HIV therapy has eroded
the sense of urgency that was so apparent in earlier years. Those favoring
other diseases are becoming more successful, getting additional funding
for breast cancer, heart disease, prostatic cancer, and injuries -- money
that earlier might have gone to NGOs or other agencies dealing with HIV/AIDS.
Such erosion of support will likely continue internationally, unless we
can demonstrate the effectiveness and efficiency of well thought-out HIV
In the United States, the public continuously debates whether tax dollars
should support programs that favor abortions, provide needles for drug
addicts, or offer sexually-explicit messages for teenagers. Often through
their elected representatives the public says "no" and local public health
programs that focus in these areas either come to a halt or are never funded.
If we want to avoid NGOs and international organizations losing financial
support for their work in developing countries, we would do well to focus
more closely on direct determinants of HIV transmission, as was done by PAHO, and less on normalizing sex work as mentioned by the UNAIDS advisor
in Cote d'Ivoire.
The price of not capturing the public's imagination with
clever and well thought-out control programs that are biologically apparent
may be too great to bear.