‘Ending AIDS in a generation’

I’ve been openly critical of the rhetoric in global HIV/AIDS policy around ‘ending HIV’.  For instance, at the MSM Global Forum pre-conference in Melbourne before AIDS2014, when US global AIDS ambassador Debbie Birx exhorted queer and trans people to ‘run a little harder’ towards the goal of ending AIDS in a generation.  This would be a little easier if so many queer and trans people around the world weren’t also running for their lives.

For many AIDS activists, the timing of the Orlando massacre was particularly painful, coming hard on the heels of the UN High Level Meeting on AIDS, where ‘key populations’ of queer and trans people, people who inject drugs and sex workers were actively excluded from deliberations and barely mentioned in the final document.

Laurel Sprague noted one paragraph in particular as a masterpiece of international policy double-speak.  I’ve highlighted the competing voices in different colours:

Reaffirm the sovereign rights of Member States, as enshrined in the Charter of the United Nations, and the need for all countries to implement the commitments and pledges in the present Declaration consistent with national laws, national development priorities and international human rights;

So the ‘run a little bit harder’ rhetoric shifts responsibility away from states and onto communities, making it sound like they’re not working hard enough to end HIV.

There is another problem with the ‘ending HIV’ rhetoric, as seen in this quote from an interview with Bill Gates, one of the largest funders of global HIV prevention:

There’s a few things where you get a slogan like “AIDS-free generation.” … I wish that were more likely. Truthfully, because we don’t have a vaccine, and the prophylactic tools, the compliance of those things has been very poor. We actually run a risk that the next generation will have more AIDS than previous generations.

It’s a story with mostly positive elements, but if you say simplistically we are on the path toward an AIDS-free generation, no, we’re not. We need more R&D, more tools. And if you’re not careful, if you overpromise, you do get this fatigue, and then, even when you still need the resources, people don’t come in.

The experience of the global effort to eradicate polio tells us that even if a preventative vaccine for HIV were discovered tomorrow, it would still take a multi-generation effort to eradicate HIV.  Consistent with Bruce Link and Jo Phelan’s fundamental causes of disease (FCD) model, we’d expect to see rich countries achieve pretty high vaccine coverage early on, and poorer countries (and disadvantaged social groups) taking a lot longer.  The crux of the FCD model is lack of access to what Link and Phelan call flexible resources like money, knowledge, literacy, and social status.

But I want to acknowledge that – at least in Australia – the ‘ending HIV’ rhetoric was in large part an intervention by canny policy entrepreneurs who sensed the winds of change in the early days of the global financial crisis, and knew to anticipate the damage that could be caused by social conservatives having a ‘good crisis’, using austerity discourse to justify huge cuts to social services and welfare.  The extended election campaign we’re having in Australia has created space for unions and social policy researchers and social services peak bodies to tell the story of the billion dollars in cuts under Abbott.

Although the HIV sector is by no means unscathed, with genuinely community-based peaks like Anwernekenhe National HIV Alliance for Aboriginal and Torres Strait Islander peoples getting completely de-funded, and the Australian Federation of AIDS Organisations losing funding for its education program to two of its own member orgs (!), my sense is that things could have been so much worse.

This is a hard one to prove — the counterfactual is a hypothetical what could have been.  But having Australia’s largest state, New South Wales, commit to an Ending HIV strategy, campaign, and program of rapid testing services and early treatment, helped keep HIV prevention on the policy agenda.  So while the science of the ‘ending HIV’ claim is questionable, that was never really the point.