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Frerichs, R.R. Biologically-based HIV control strategies

SEA-AIDS Network, March 30, 1998.

R.R. Frerichs Posting

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) states: "In 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 control strategies.

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.