A spirited debate about the HIV epidemic in Africa is brewing in the blogosphere! It started with the UN's latest report about HIV infection worldwide. This inspired NZBear to post horrific chart comparing projected deaths due to HIV/AIDS to historic deaths from other global tragedies such as the Holocaust and the forced famine in the USSR (he carefully documents his data sources).

The logical course of action is to try and treat the infected in Africa so that the disease doesn't spread and we don't see the horrible projected outcome (whose proportions NZBear graphically illustrated). That way we can potentially save 68 MILLION people from dying of AIDS. However, Den Beste has a defeatist counter proposal - we should consider letting them die.

Its important to separate Den Beste's arguments from his conclusion. (scroll past the triage stuff, it's not really relevant.) The points he notes are that:

[1] the situation seems hopeless because HIV infection rates are so high
[2] sending money to Africa is a guarantee of money being wasted, not a guarantee of succesful treatment
[3] treatment is useless if the people continue sexual practices which contribute to infection rate

these are essential points that must be addressed in any policy that tries to address the problem of AIDS in Africa. However, Den Beste extrapolates them to conclude that treatment would lead to MORE deaths (ie, treated people woudl keep spreading the disease, as opposed to dead people who can't spread the disease further). He then invokes his triage analogy to justify this "tough love" approach of letting them die to save lives.

These conclusions are based on certain assumptions of Den Beste's which are in fact false:

[a] 100% of HIV-infected people die from AIDS.
[b] people cannot be educated to stop the sexual practices which lead to spread of teh disease
[c] treatment is expensive and will be a huge drain of resources

Starting with [a] - it is important to keep in mind the distinction between HIV and AIDS. HIV is a condition, which if untreated, leads to AIDS. AIDS is what kills you - because AIDS destroys your immune system and you get sick from something innocous which you no longer have a defense against.

There is a lot of data that demonstrates that the AIDS death rate is NOT equal to the HIV infection rate:

In fact, the mortality rate in the US (where treatment is available) is far lower than for other causes such as heart disease, diabetes, etc.:

So the goal should be to reduce the mortality rate of the disease. Its true that if a person infected with HIV lived in a bubble, isolated from the world, and had zero treatment, then they would die of AIDS. But put that person in the real world, and they might die from heart disease long before they die of AIDS. Give them treatment, and you can make that a certainty.

Note that as treatment options become available, the survival rate increases DRAMATICALLY. Look at this data:

where the drastic increases in just first-year survival jumps from 40% to 60%, then from 60% to 80%, correlated with the introduction of new treatments.

Clearly, treatment will improve survival to the point where the infected person is more likely to die from other causes than from AIDS.

So, this leads to point [b]. Suppose we do increase the survival rate by providing treatment. Den Beste argues that this will lead to higher infection rates because people who are infected and alive will spread the disease. People who are dead cannot. This assumes that education has zero effect, but this is demonstrably not true. For example, in the United States, AIDS infection among homosexuals was enormous at the outset of the epidemic, peaking in 1995. But as education took hold, the death due to infection decreased and has now stabilized.

Finally, what about point [c] ? Having established that treatment works to reduce mortality and that education reduces infection, how are we going to pay for it? But the answer is that we do not need to pay for it. Brazil has defied AIDS drug patents to manufacture the drugs for treatment locally, invoking the sovereign power of eminent domain. The drug companies quickly capitulated, offerring huge discounts, realizing that it was better to get something rather than nothing. The US also took a supportive role in this:

President Clinton declared in an Executive Order that the United States will not seek to revise the intellectual property laws of sub-Saharan countries that use domestic law to provide access to HIV/AIDS medications, provided that they adhere to the TRIPS agreement.

And despite predictions to the contrary, the Bush Administration has remained steadfastly in support of the Executive Order. Moreover, in April of this year, 39 of the largest drug companies in the world announced that they had decided to drop a lawsuit to prevent South Africa from purchasing generic versions of their patented AIDS medicines.

That's a good PR move on their part, but it is also the moral thing to do. Drugs are like software, the cost is in the development. Suppose there are millions of people who need your drugs, and they cant afford it and they die. Suppose instead that those millions of people are given generic versions of those drugs and they live. Either way, your economic position as a drug company is unaffected - you get nothing. There is no disincentive for drug research by taking this course of action, as the drug companies claim. In fact, as Roche and Bristol Myers and other companies also realized, might as well make some profit off the transaction.

The Findlaw article is excellent reading and provides a thorough discussion of the legal issues and the practical issues. It's a wonderful example of principled pragmatism. Patents can and should be modified in times of need - surely John Ashcroft would agree, since he has the same attitude towards the Bill of Rights :) As the article points out:

This exception for patent protections�in times of public need or emergency�has thus raised deep-seated questions about the nature of intellectual property itself, defying many of the commonly held assumptions regarding the protection of inventions.

So, having illustrated why assumptions [a]-[c] are false, then it is possible to look at the important issues [1]-[3] in a less reactionary way. Certainly, compulsory licensing via eminent domain is an option, but treatment cannot be relied on exclusively. A comprehensive education program, run by third party health organizations, is essential as a complentary aspect. With both treatment and education, we can save millions of lives.

Demosthenes has a response which in my opinion unfairly accuses Den Beste of putting economic concerns first - which Den Beste denies, pointing out that his analysis was based on the assumption that Western nations buys all the required drugs. Den Beste is claiming that the treatment will make things worse. It's true that he opposes the cost of teh treatment, but that doesn't factor into his analysis. Demosthenes makes an more solid critique of Den Beste however:

Second, there is a disturbing amount of eugencism in this argument. After all, the only difference between HIV and a genetically transmitted disease is the time frame- both are the results of sexual behavior, and both are (in many cases) uncurable. Any argument that we should simply "let the AIDs patients all die off" can and will be extended to the argument that we should let people with, say, cystic fibrosis die off, so there's no chance that they could pass it on to their children.

"But wait", some are no doubt saying right now. "Cystic Fibrosis is a recessive gene!" That is true, of course, but that leads into my third point: HIV is a "recessive" disease. Killing off each and every AIDs patient right now will do practically nothing to stop the spread of the disease, because it can be transmitted between those who not only don't show signs of AIDS, but who don't even test positive for HIV yet. Letting those who show symptoms or even merely test positive die off would mean absolutely nothing, because the virus would still be spreading no matter what we do. (This was the stake through the heart of the "apartheid argument" back in the day, and remains as true in Africa as it did in North America).

There is a wealth of information at the CDC website. In my opinion, this is required reading for anyone daring to suggest drastic solutions of any kind.

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