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HIV Treatment vs Prevention Debate must Reconcile the Post-MDG Development Agenda Focus on Social Determinants and Human Rights

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India.
Country - ies of focus Global, India
Relevant to the conference tracks Advocacy and Communication
Summary With recent scientific advances in HIV, an old debate based on the treatment-prevention dichotomy is re-emerging. One side appeals that resources must now be diverted from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues, among other reasons, that treatment can realistically reach only a small subsection of those in need of it. Therefore investments in prevention need to be furthered in order to effectively contain HIV. This paper analyses the HIV prevention vs. treatment debate in the context of a post-2015 development agenda, particularly in light of Social Determinants and Human Rights.
Background With the global flat-lining of resources for HIV, there are appeals to prioritize based on reasonable resource allocation decisions and a search for high impact interventions that maximize ‘benefit’. In this context, and with recent scientific advances in HIV on the preventive benefits of Anti-retroviral Therapy (ART), an old debate based on the treatment-prevention dichotomy is re-emerging. One argument is that resources must now divert from conventional prevention strategies towards early treatment as it can prevent new infections. The other side argues that treatment can only realistically reach a small subsection of those in need so prevention investments need to be furthered in order to effectively contain HIV. Amidst the treatment vs. prevention debate, with the backdrop of the global financial crunch, concerns emerge as to how the goals of zero new infections and zero AIDS related death can be achieved as agreed upon by member states at the United Nations High Level Meeting in June 2011. Incidentally, the Millennium Development Goals of which halting and reversing the HIV epidemic is a key target, will soon give way to a new development agenda in the post-2015 period.
Objectives Public health professionals and national governments face this ethical challenge – whether to take the side of treatment or prevention. This paper aims to address the resource allocation dilemma arising from the choice whether to prefer HIV prevention or treatment in programs run by governments, by comparing the merits and demerits of the two positions from a public health point of view. It explores different theories and approaches which could be used for the analysis. Apart from this primary objective, the paper aims to feed into the post-2015 development agenda by proposing an integrated approach to several interconnected challenges encompassing not only HIV, but Social Determinants of Health, Human Rights, and Equitable health.
Methodology The main aspect of the methodology used in this analysis is to compare and contrast the two divergent positions:Position 1: With the evidence on “Treatment as Prevention” to divert scarce resources from prevention towards treatment: Position 2: Re-allocating funds from prevention budget to treatment is faulty as strengthening prevention is the way forward.The approach for analysis is to examine the following dimensions:i. Merits and Demerits of the two positions

ii. Problems in subscribing to either of the two

iii. Possibility of an alternative position

iv. Lessons from the past in related areas

Within this broad framework, the analytic methodology adopts a systems approach with an understanding that interconnected challenges need integrated solutions. Political and contextual factors, especially those related to power differences get too little attention in many of our discourses especially the ‘high theories’ (Arras J, 2010). In the process, individuals and groups with different types of vulnerabilities based on factors like gender, poverty and race tend to be disproportionately skewed in their respective risk-benefit equations. By ignoring the political and contextual factors related to power imbalances, people with different vulnerabilities tend to receive more harm than others. (Bertomeu M, 2009). Feminist approaches try to address this gap by adopting a bottom-up approach as opposed to some of the traditional theories that are top-down, abstract, and deductive in nature (Arras J, 2010; and Beauchamp TL, 2009). Accordingly, people who are otherwise oppressed or devalued in society are considered in discourses about policy options (Sherwin S, 1999). Moreover, critiques have pointed out the inappropriateness of using theories and approaches which were originally designed in the context of clinical ethics or research ethics for the purpose of public health ethics. (Baylis F, 2008, and Kenny N, 2010). Hence, we need an systems approach to research methodology not only considering health systems, but also integrating Social Determinants of Health, Human Rights, and Equity.

Results Even after three decades of responding to HIV, prevention programming continues to be ‘largely deficient’ (Bertozzi SM, 2008). Hence some proponents of the test and treat strategy, citing recent evidence, argue for the diversion of resources towards scaling up Antiretroviral Therapy (ART) as a strategy for HIV prevention. Yet, conventional prevention modalities continue to be the most inexpensive options. One of the arguments against conventional programs among sex workers is that condom use is not universal. It is often pointed out that sex workers tend to agree to transactional sex without condoms if there is a premium in the payment over and above what they get for sex with condom. However studies have identified the factors that make women vulnerable to such compromises (de la Torre A, 2010). Hence, prevention programs must broaden to influence structural determinants that make women vulnerable rather than totally denouncing behavioral and non-biomedical modes of HIV prevention. Studies also report that people who are treatment optimistic or who believe that ART can reduce the viral load and hence HIV transmissibility, tend to indulge more in risky sexual behaviour (Brennan DJ, 2010). This is especially profound when we consider education levels and other factors like power relations in the provider-patient relationship. The results of the detailed (not included here due to space constraints) analysis did not favor one over the other in the treatment vs. prevention debate. However, the analysis led to an alternative position where it is demonstrated that the treatment-prevention dichotomy is in fact irrelevant in the context of recent scientific advances that profess the very concept of “Treatment as Prevention”. By opting for an integrated continuum model, HIV programs can still have treatment as one of the options in a combination prevention strategy. By doing so, HIV programs demolish the water-tight compartments of treatment and prevention, thereby leading to a more realistic path towards the goals of zero new infections, zero AIDS related deaths, and zero discrimination. This approach is crucial to uphold the rights and interests of those who are marginalized in society due to different socio-political, economic and cultural factors. In the absence of a holistic approach relevant to the local contextual factors, issues of the marginalized will skip the frameworks created for monitoring and evaluation of programs; and hence remain unaddressed.
Conclusion Analysis of the two conflicting positions has demonstrated both advantages as well as disadvantages of these positions. Any bias towards treatment or prevention in a public health scenario tends to overlook some issue or the other and is faced predominantly by the oppressed or otherwise less-valued groups of people in the society. It is in this context that this paper argues to strengthen the prevention-treatment-care continuum. This has been proposed earlier, before the recent advances that led to calls for ‘test and treat’ strategy based on the premise of ‘treatment is prevention’ (de Loenzien M 2009; and Simon V, 2006). Further within this broader continuum model, a continuum of prevention is also identified: one which takes into consideration not only the uninfected, but also infected persons at different clinical stages ranging from asymptomatic individuals to those who clinically require ART and other advanced forms of care (Simon V, 2006). HIV policies and programs in some developing countries have taken this model to higher holistic levels by including palliative care in the continuum model. At the same time, they have acknowledged the need to address other larger issues like poverty, gender-based power differences, and other health issues - especially reproductive health issues, which are also determinants of success in HIV control programs (de Loenzien M 2009). Thus we can see that by over-emphasizing a medicalized model through a test and treat strategy, national HIV programs will be missing crucial opportunities in addressing larger human development issues. Even within the domain of health, an HIV prevention strategy predominated by early ART alone ignores the interconnected challenges including other sexually transmitted diseases and the social factors that determine many diseases which are disproportionately prevalent among poor and socially marginalized sections of society (Reading JL, 2009). Success in HIV prevention programs has been shown to be associated with measures to address gender disparities, counter stigma and discrimination and mobilize affected communities (Merson MH, 2008). A continuum approach or an integrated one has also been shown to provide a human rights framework for examining state responsibility with respect to obligations towards a wide range of people whose lives are infected and affected by HIV (Walker E, 2007). In the move from MDGs to post-2015 agenda, such integrated approaches must guide us.

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