Commentary: Getting to Zero

Why Medical Science Alone Won’t Yield an AIDS-free Generation
Wed, 11/30/2011

Imagine this: A pregnant woman is infected with HIV, but she doesn’t know it. She’s unaware she could transmit the virus to her baby. However, if she were to take a pill at the right time during her pregnancy she could drastically reduce the chances of transmission. Sadly she does not, and another generation is born into the world living with HIV.

Tragic, preventable scenarios like these continue to play out again and again across the developing world today. Despite advances in the development and roll-out of antiretroviral drug regimens, 400,000 children were born with HIV in 2010, according to the latest report from UNAIDS.

The reasons why are varied and complex. The short answer is that medical approaches, such as drugs to prevent mother to child transmission, will inevitably run up against the obstacles of people and societies – their behaviors, motivations, and cultural and social norms.  This can play out in a variety of ways: A woman decides against testing for fear of the stigma and discrimination that could come with a positive diagnosis. An HIV-positive mother cannot make it to the clinic for her treatment because it’s far from her home and the cost of transportation is too high or because she can’t afford to give up a day’s work in the fields.

Poverty, gender inequality, stigma and discrimination – these are invisible factors that increase an individual’s vulnerability to HIV infection, seriously undermining global prevention and treatment efforts. Thirty years into the epidemic, we still have more questions than answers when it comes to untangling how human behavior and social forces influence HIV vulnerability and developing interventions that work to mitigate them.  

There are those who believe the underlying causes of HIV vulnerability are too complicated to be addressed by donor-funded global health programs. It’s much easier to count the number of people on treatment than it is to understand why a pregnant woman would turn down a chance to give her child a healthy start in life.  Yet, complementary social science research is critical to fulfill the promise of medical breakthroughs like male circumcision, female microbicides and ultimately, perhaps, a vaccine. We must address social change in tandem with medical innovations to achieve zero new infections, zero discrimination and zero AIDS-related deaths.     

It’s a challenging approach. It will require more collaboration across many scientific disciplines. It will mean financial investments that encourage large, innovative studies. Take stigma and discrimination as an example. AIDS workers and researchers have long identified it as an entrenched barrier to prevention, treatment and care. Thanks to a decade of research and program work, we know what causes stigma. We know its consequences. And we have strategies that can effectively reduce it. Implementing a large-scale randomized study of a stigma-reduction intervention would yield much needed evidence on how such programs could be replicated. It has yet to be done.

To be fair, some trailblazing donors are focused on understanding the social drivers of HIV infection. The U.K.’s Department for International Development (DFID) is funding a multidisciplinary consortium of research institutions, led by the London School of Hygiene and Tropical Medicine and including ICRW, to investigate how to ameliorate the social factors that compromise HIV prevention and treatment.  ICRW recently completed a three-year project, funded by the Bill & Melinda Gates Foundation, to identify how gender issues that put women at risk of infection can be addressed in national HIV plans. But we need much more.

The world has made tremendous progress in the fight against AIDS, so much so that an end to the pandemic is in sight. In a recent speech, Secretary of State Hillary Clinton urged the global community toward achieving an AIDS-free generation and recommended that science guide our efforts.

“Success depends on deploying our tools based on the best available evidence,” she said. We could not agree more. But to get there, the evidence base must include all the scientific solutions – both medical and social.

Katherine Fritz is ICRW's director of global health.

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