Elizabeth Pisani sounds off about why HIV treatment is a bad thing

Hi bathousers,

Sorry for not posting for a while but to make up for it here here’s a quick post about an article written by Pisani, in which she provides anyone wanting an excuse for not funding ARVs in Africa. Brilliant.


In this article, as ever, Pisani seeks media attention by making a point in an inflammatory and simplistic way.

This is in response to another story, in which some researchers have suggested that screening and in some cases blanket prescription of ARVs could prove effective.

In this case her argument runs like this:
1.) The AIDS mafia want treatment to replace prevention in Africa because they think that people on ARVs are less infectious, therefore reducing the spread of HIV.
2.) What the fools don’t realise is that people are most infectious soon after having contracted HIV so the screening is unlikely to help identify people in time
3.) Availability of treatment makes people less worried about HIV and so indulge in more risky behaviours
4.) Treatment is bad and people who think it is a good idea are optimistic simpletons

This ignores several important factors. Firstly the scientific argument, obviously there will be a decrease in inflections if everyone who needs drugs gets them as viral load is reduced, but this effect will not help those infections that take place before people have received treatment. Clearly then, the balance between effectiveness and screening interval needs to be considered. Annual screening could reduce all infections which aren’t caused by newly HIV+ people. No doubt this is still a significant chunk, though this is not the most risky time. It will also catch a good amount, though by no means all, people while they are at their most infectious. Assuming people are at their most infectious for several months you will find 8.3% (100/12months) of people in their first month and 25% of people within their first three months. This is still a big reduction. To increase this rate further you could increase screening intervals, perhaps of ‘at risk’ groups to achieve greater success.

As the true effectiveness of the idea will depend on loads of diverse factors, the only way to really know how well this will work is to do a trial. This is actually what is being proposed, so the whole thing sounds very sensible to me.

Secondly, the moral argument. You really can’t just go letting people die preventable deaths. If it costs money to bring the new infections and deaths under control in a way that rich counties have, then that is money well spent.

Once we acknowledge that it is morally right to reduce the spread of HIV the interesting question, and the one the researchers will set out to answer is “is screening and increased access to ARVs more effective, cost effective and practical than other forms of prevention?” That question won’t be answered by misrepresenting the augment as if the researchers have made a basic error in understanding the virus.


7 thoughts on “Elizabeth Pisani sounds off about why HIV treatment is a bad thing

  1. Pingback: HIV / AIDS Treatment » Elizabeth Pisani sounds off about why HIV treatment is a bad thing …

  2. Thanks for drawing attention to my article in this way. Being a media whore, I’m obviously thrilled by any additional attention I get…

    Seriously, if you wish to reduce my argument to the inflamatory and simplistic, then I don’t take issue with points 1 through 3 of your summary. But I take very serious issue with point 4. I cannot understand how you get from the facts (in most communities with high HIV prevalence where HIV testing is actively promoted and HAART has been available to everyone for more than a decade, HIV incidence is rising) to the assertion that “treatment is bad”.

    Treatment is good because it reduces damage to the immune system, reduces infections associated with HIV, keeps people alive and allows them to lead healthy and presumably happier lives. You do not need spurious arguments about treatment being a substitute for HIV prevention to justify rolling out treatment as widely as possible. But to keep treatment even remotely sustainable, you have to be realistic about effective prevention. The more treatment we have, the more effective prevention we need. How that makes me “anti-treatment” is a mystery to me.

  3. I apologise that I’ve misrepresented and simplified EP’s argument and I thank her for taking the time to comment.

    I meant the argument in the post above to represent the thought process of a reader rather than EP’s own views, I realise that the conclusion “treatment is bad” is unfair. I also don’t suspect her of being anti-treatment. I’ve read her book (http://www.wisdomofwhores.com/) and I it was an eye opening introduction to the world of epidemiology and the politics of health. In EP’s writings and public speaking event’s, of which I’ve been to one or two. I believe, and forgive me if I simplify again, that she objects to interest groups ignoring evidence on the basis of ideology and if the evidence suggests something is ineffective then someone should say so.

    While I broadly agree with all of this, I think as someone with as much authority as EP has to be aware about how their comments will be received and this kind of article can muddy the waters around whether universal access to treatment is a good thing or not. The web address for the article was, after all ended with “the-drugs-wont-work”.

    Sorry if I caused any offense and thanks for stopping by.

  4. Pingback: peripheries » Blog Archive » Treatment as Prevention: The Agony and the Ecstasy

  5. I agree with Pisani in Comment is Free that the realities of HIV do depend on geography, and that there is ‘more’ to be considered in approaching treatment, but would like to point out the obvious, that it is so much more than her post suggests. That “more treatment means fewer infections” is, I quite agree, “not that simple”. The remedy to continued appalling rates of HIV infection around the globe is not an easy case of popping a pill for HIV everyday. I do take issue with Pisani’s comment that this is “Boring, but not the end of the world” however.

    My concern also applies to thebathhouse’s comment which suggests too, “the true effectiveness of the idea will depend on loads of diverse factors”.

    The ‘loads of diverse factors’ are just those that confound the WHO mathematical model, and are just those which create the situations and contexts in which HIV emerges: poverty, lack of basic resources crucial to living healthily, such as lack of water, food, security, safety, political unrest and everyday violence which can be both massive and mundane in its scale.

    They confound the WHO model because, as much anthropological research has shown, the practice of biomedical treatment outside the ‘privileged’ context of western countries does not follow predicted paths of treatment and effect. The availability of essential drugs does not mean they are used in an endorsed manner, particular to guaranteeing better health. What research does show is that it is paramount to consider the ‘totality of conditions’ when considering the problem of treatment and infection. This is an idea drawn from Veena Das, and bear with me, it’s not some floaty academic excuse for not getting one’s hands dirty and not acting out of moral necessity. Whilst HIV/AIDS present a massive threat to global health, what is often more devastating for those who live with the diagnosis of this disease is this totality of conditions in which they live. The conditions of poverty, through which the disease surfaces, are often of greater importance for those who are living with these conditions. A diagnosis of HIV, and the ‘boredom’ of taking a daily drug cocktail to remedy that diagnosis, is not.

    This is important to consider. Whilst I agree in the absolute sensibility of conducting a trial, and of providing treatment, it doesn’t help to defend the WHO proposition as a clear ethical argument. We should be worried about a blanket-testing treatment programme which is premised on the idea that African people can’t be trusted to deal with their illnesses and seek treatments in a rational manner – believing that the only way they will benefit, as a collective public, is to enforce testing and treatment regimens. They are not irrational idiots to be solved by the rational policies of global public health and statistical predictions. And we should not be underestimating the force of global economic processes on the production of infection. Rather, we should cast an individual’s descision making and ‘risk-taking’ in terms of the choices that confront them – those of hunger, for instance, and instability, and have the courage to confront those too. We can’t expect to ‘solve’ HIV transmission by means of a policy model which fails to engage with the everyday realities of people living with or at risk of infection.

  6. In follow up to Rebecca, and to sort of echo peripheries’ question, I have a few sketchy thoughts. I think the Pisani article helps raise the anthropologists’ favourite issue – practice. Is it more fruitful to think of development as policy statements – blanket testing and treatment for all – or practice.

    The development industry has to be more concerned with policy statements that mobilise funding and the support of a diverse set of interest groups – NGOs, Governments, Electorate, WTO etc – than about how the policy unfolds when it’s implemented.

    What the Pisani article and Rebecca’s comment help articulate is that policy is undermined by all sorts of mundane human factors. To maintain ARV treatment you need to eat, you need to make it to the clinics regularly etc. This doesn’t, in itself, undermine the policy prescriptions, but I think the gap between policy and practice is not thought about enough when considering development intervention.

    From my perspective development is, like everything, a case of competing interest groups. Policy is a tool to align some interest groups, which by definition, marginalises others. I don’t know enough about the development health industry, but I guess a policy of blanket testing and treatment will be fantastic news for Big Pharma and other health-delivering organisations, alongside having plenty of other consequences.

    This is all very obvious and it doesn’t undermine the policy, but 50 years of evolving policy statements have had pretty unsatisfactory development outcomes, so how else can we think about it all?

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