10/13 Response to Readings

The primary idea in the Iliffe reading that I found very intriguing revolved around the concept of discrimination and individual patient rights in Western AIDS policy versus African AIDS policy. I had previously viewed the prevention of stigma and discrimination against HIV/AIDS patients as a key component of HIV/AIDS prevention and treatment. However, I was unaware that much of the focus on avoiding discrimination eminated from the work of American AIDS activists and their influence on the WHO. Discrimination should obviously be combatted vigorously in infected communities. Yet I think it is crucial to recognize, as Iliffe suggests, the distinction between discrimination in HIV/AIDS communities where high-risk minority groups define the epidemic versus communities where the epidemic is widespread among the general population. Perhaps the spread of the epidemic in Africa could have been limited somewhat more successfully if Mann's focus on individual rights had not been quite so stridently pursued, and instead had been balanced by concern for the uninfected public.
Iliffe's chapter on "NGO's and the Evolution of Care" also struck me as interesting. As Iliffe discusses, the world had not yet experienced an epidemic in which non-governmental organizations played such a large role before the HIV/AIDS epidemic. Yet, as was the case in South Africa, the role of NGO's was often dictated by the relationship between the NGO sector and the government in any given country. In South Africa, tensions concerning the delayed rollout of ARV's and MTCT regimens under the Mbeki government caused severe rifts between NGO's and the South African government, limiting the ability of the two sectors to work together in fighting the epidemic. The evolution of the home-based care system under various NGO's is just one example of the potential power of these organizations to support and supplement government HIV/AIDS policies. Home-based care seems to have arisen to support a need for care that many African health systems could not provide; however, this system did not provide the complete medical care that most patients needed, and this is where government health systems needed huge improvement.
The primary points that I took away from the Mwanza and Rakai trials were that first of all, sustained health care, or in this case consistent, long-term treatment of STD's, is more effective in combatting the spread of the epidemic than short, mass treatments, as was the case in the Rakai trial.
I was surprised by Pott's assertions that there is little evidence suggesting that condom use and HIV testing have played any significant role in halting the spread of the epidemic in sub-Saharan Africa. These two tenets of HIV/AIDS prevention are so well-established, that I assumed they were supported by significant data. Furthermore, I was stunned by the fact that modeling suggests that male circumcision "could avert up to 5.7 million new HIV infections and 3 million deaths over the next 20 years in sub-Saharan Africa," and found Pott's point that donor funding needs to be redirected towards proven prevention strategies to be very valid. Many other strategies, such as increased condom use, may prove very effective in the future, but international focus should remain on prevention strategies that are backed by significant data.