In an age where there is proper and successful treatment of HIV/AIDS, is the public health approach to it of public health significance? This may seem like a rhetorical question, but there are plenty of people out there who would like to see HIV moved into a category of diseases that “just happen,” like so many sexually-transmitted infections which we now just hear about and shrug our shoulders. They want HIV-infected individuals to be a group that healthcare providers deal with, not public health authorities. They want screening for HIV infection to be a personal matter that people do because they want to be healthy not because we tell them to for the good of The Herd™.
After all, Cuba no longer has mother-to-child transmission of HIV, and life expectancy for people living with HIV are is getting closer and closer to the average (with some caveats). But thinking that these good news somehow justify a move from public health models to purely clinical models of dealing with HIV is a very narrow way of thinking. It might even be a little bit dangerous.
Unless you’ve been living under a rock, you know the story of HIV and AIDS. It all started in the 1970’s, when the first few cases were reported of a new disease where a person’s immune system was obliterated. There is some evidence that HIV had entered the human population much, much earlier than that, but we’ll stick with this story because it wasn’t until the 1970’s that critical mass was reached in the number of people who were infected in order for it to become a pandemic. The 1980’s brought the greatest rise in the number of cases and awareness about HIV/AIDS. Along with the pandemic came denial and ignorance about the people being infected. To many who were not infected, those who were infected were any number of things but people.
I remember I was in the 5th grade (circa 1989), when a friend of mine asked me if I knew what AIDS was. I had heard about AIDS on television, but I didn’t really knew anything about it. He very confidently told me that I need not worry about AIDS because I wasn’t gay. “You’re not, are you?” he asked in an accusatory tone. I remember shaking my head furiously and wishing that I wasn’t… See, I had no idea what “gay” or “straight” was. Because I didn’t know, there might be a chance that I was, and, thus, there might be a chance that I could catch this AIDS thing that was killing so many people. This is all hogwash in retrospect, but it has stuck with me as a lesson in what ignorance and fear can do to a public health problem.
Luckily for us, the 1990’s brought with it acceptance and action against HIV/AIDS. New medications were developed to combat the HIV infection from progressing to AIDS and to allow most people with AIDS to regress to an immune status that would allow them to live longer. These efforts only increased in the 2000’s with programs aimed at delivering these drugs all around the world to the most needy. Programs like PEPFAR and others started to save lives in places like Africa — where HIV and AIDS have caused the most strife — and Asia. Latin American countries announced plans to give medication for free or at reduced cost. The wealthy and socialized medicine programs of Europe, Canad, and the Far East followed suit. Insurance companies in the United States began to cover the costs of medication and, with the advent of the Affordable Care Act (aka Obamacare), they could no longer deny coverage to people who were previously infected.
In a perfect world, this would be the last decade that would see HIV and AIDS as a pandemic. In the next five to ten years, medication and awareness and action against HIV infections would be so widespread so as to render new cases a rarity and keep currently infected people alive long enough to die from something else. But this is not a perfect world, is it?
There are enormous inequities and inequalities within populations and between populations. Even in the United States, with all the advanced medical technology that politicians like to tout, we have communities and subcultures who continue to be hit hard by new HIV infections and lack of access to treatment. Or, if treatment is very successful, we have a situation in which being infected with HIV is seen as not a big deal… Which loops right back to the opening of this post.
HIV and AIDS continue to be big, significant public health problems not because they’re conditions that cannot be treated or managed. They can, successfully, even. They continue to be significant because they’re a very deadly consequence of all the other systemic problems that we humans face in how we treat each other, how we take care of ourselves, and how we come together to solve problems. Had there been less fear about the “Gay Related Immunodeficiency Disease,” as AIDS was called before it was fully understood, we might have been able to give effective public health information that could have slowed down the epidemic. If that kid in 5th grade — and anyone else just as impressionable — had received a message that everyone and anyone can get infected with HIV, then maybe everyone would have acted, and the fear and stigma that accompanied an AIDS diagnosis could have been reduced.
If those who were at highest risk of being infected took that risk seriously and practiced safe sex, then maybe the epidemic could have been slowed down. And if the people in power had not covered their eyes and ears in the face of the initial outbreak but instead committed all available public health resources to stopping it… Well, you know the story.
Don’t be deceived into thinking that HIV and AIDS are things of the past simply because there are effective drugs to manage the infection and to bring people back from the brink should they develop AIDS. We still have a ton of work to do, and there is a lot to be learned on how to work together across different disciplines to bring this thing fully under control. We also need to overcome our human tendencies to mistreat those among us who are “different” and to fight ignorance with fear instead of fighting it with knowledge and reason.
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
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