Adrian Flint

Reconciling the Irreconcilable? HIV/AIDS and the Potential for Middle Ground Between the Traditional and Biomedical Healthcare Sectors in South Africa

This article analyses, from a policymaking perspective, the continued recourse to South Africas thriving traditional healthcare sector, which operates in tandem with the countrys relatively well-developed biomedical healthcare sector. It considers the traditional healthcare sectors potential to impact on orthodox approaches to the treatment and management of HIV/AIDS, including the uptake of antiretroviral therapy. It highlights the urgent necessity of more thorough engagement between the traditional and biomedical sectors, particularly where supernatural elements – an integral part of much traditional diagnosis and treatment – are concerned. The challenge for policymakers is how best to facilitate an effective means of meaningfully accommodating potentially conflicting traditional cosmologies within the formal healthcare infrastructure. However, although the achievement of this would represent a vital step towards a more effective overall approach to South Africas HIV/AIDS pandemic, this article queries whether it is indeed feasible.

Ownership and Participation: Toward a Development Paradigm based on Beneficiary-led Aid

This article makes the case for a development paradigm shaped and determined by the people affected directly by aid and assistance programs: in essence, it is a call for beneficiary-led aid (BLA). Over the past two decades, input from beneficiaries has become increasingly important in the design of development programs. At the same time, the donor model remains one that is top-down, agenda driven, and expert led. Similarly, the use of information and communications technology (ICT) by donors in the interests of facilitating closer engagement with beneficiaries has been ongoing for over a decade. However, while the ICT4D (ICT for development) model has generated a great deal of enthusiasm within the donor community, the approach has yet to generate a discernible paradigm shift where the provision of aid and assistance is concerned. Taking inspiration from initiatives both within and outwith the field of development, we explore the extent to which ICT can indeed offer a route through which to revolutionize the meaning of “participation” in an aid context, for beneficiaries, donors, and development experts alike.

Colonial tropes and HIV/AIDS in Africa: sex, disease and race

One of the features of the African HIV/AIDS pandemic has been the re-emphasis of Africas place in the global imagination as the ‘sick continent’, the ‘diseased continent’ and the ‘dark continent’. Much of the early discourse on HIV/AIDS in Africa – intentionally or not – helped to cement a longstanding outsider idea of Africa as a place where health and general well-being are determined by culturally (and to a degree racially) dictated modes of sexual behaviour that fall well outside of the ‘ordinary’. Early HIV/AIDS discourse have much in common with colonial-era narratives on African ‘venereal disease’ pandemics like syphilis in the late nineteenth/early twentieth century – noteworthy, in both instances, was the view that African people needed saving from themselves. By analysing historical responses to these two pandemics, we demonstrate an arguably unbroken outsider perception of African sexuality, based largely on colonial-era tropes, that portrays African people as over-sexed, uncontrolled in their appetites, promiscuous, impervious to risk and thus agents of their own misfortune.

Intellectual Property Rights and the Potential for Universal Access to Treatment: trips, acta and hiv/aids medicine

Abstract Where hiv/aids is concerned, the twin goals of ‘zero new infections’ and an ‘aids-free generation’ are now, due to advances in treatment (and treatment as prevention), a realistic possibility. However, these goals can only be achieved through the scaling-up of treatment to the point of universal access. It is inevitable that the success of any scaling-up will be predicated on cost, particularly of hiv/aids medicines. This article argues that recent changes in the global intellectual property landscape—effected by way of bilaterally- and plurilaterally-negotiated trade agreements initiated by developed countries—jeopardise the target of universal access. Enhanced protection of international intellectual property rights increasingly poses a threat to the development of, and international trade in, generic medicines. Unless developing countries move to reinvigorate moribund multilateral institutions, particularly the wto, they will lose control of the intellectual property agenda, and thus the ability to impose an alternative vision regarding universal access.

The Origins of HIV/AIDS

Why has Africa suffered so disproportionately from HIV/AIDS? This is the question at the heart of this study. One possible explanation relates to the origins of HIV, the virus that causes AIDS. The bald statistics bear repeating: by late 2008, an estimated 33.4 million people were infected with HIV/AIDS worldwide. Sufferers in sub-Saharan Africa made up two-thirds of this total (UNAIDS 2009a). That HIV originated in Africa is, conspiracy theories aside, undisputed. This being the case, it is hardly surprising that HIV/AIDS managed to gain a strong foothold on the continent. After all, HIV was not identified positively until 1983 and even then remained little understood for some years. A simple answer, therefore, to the question of ‘why Africa?’ is that Africa represents ‘ground zero’ (Iliffe 2006).

Sex and Disease: A Historical Perspective

There is a scene in the film Blood Diamond (2006) in which Leonardo DiCaprio’s character, Danny Archer, attempts to explain the roots of the ‘African Crisis’ to a newly-arrived American journalist played by Jennifer Connelly. Archer sums up the situation with a pithy acronym, ‘TIA’ — ‘this is Africa’. The implication is that Africa is somehow both unknowable and inexplicable; a continent in which the normal ‘rules’ do not apply. It is due to the pernicious spread of this view across much of the developed world that a degree of ennui has crept into people’s perceptions of the HIV/AIDS pandemic in Africa. HIV/AIDS is often treated as though it is without precedent, that it is unique in terms of African development; a disease lying outside the realms of historical context. There has also been an increased tendency on the part of policymakers to identify what makes Africa, and Africans, ‘different’ where HIV/AIDS is concerned. This chapter will address these trends, locate the disease within the broader ‘African Crisis’ and place HIV/AIDS within an appropriate historical context.

Governance, the International Trading System and Access to Antiretrovirals

The question of universal access to life-saving drugs like antiretrovirals is inevitably emotive. ARVs are the only proven means of staving off AIDS. That so many in Africa do not have access to ARVs is clearly problematic, both morally and medically. The need for a comprehensive biomedical framework for African states has never been more urgent. An obvious starting point for consideration is cost. Here, the HIV/AIDS story comes with a ready made villain in the shape of the multinational pharmaceutical giants, perceived by some critics to be making billions of dollars in profits whilst people across sub-Saharan Africa die. Campaigners pressing for universal access to ARVs point to the influence of ‘Big Pharma’ in driving and shaping both American and WTO policies on the protection of intellectual property rights with respect to the patenting of their products. The extension of these rights across the globe has cemented the major drug companies’ control over the international pharmaceutical market and, with it, their ability to control prices and access. The rules regulating the governance of international trade are thus pivotal to the future of HIV/AIDS treatment, particularly in poorer countries where price concerns can mean the difference between life and death.

The International Response: Multilateral and Unilateral Approaches

The international community was slow to respond to HIV/AIDS in sub-Saharan Africa. For much of the 1980s and 1990s, funding remained limited. However, pressure to respond to the crisis led to the formation of three key donor programmes: The World Bank’s Multi-Country HIV/AIDS Program for Africa (MAP), established in 2001 The Global Fund to Fight AIDS, Tuberculosis and Malaria (henceforth ‘Global Fund’), operational since 2002 The US President’s Emergency Plan for AIDS Relief (PEPFAR) authorized in 2003.

Morality, Behavioural Change and the Search for a ‘Social Vaccine’

In the absence of an HIV/AIDS vaccine, and against a complex sociopolitical and economic backdrop, endeavours to formulate a successful strategy to stay the HIV/AIDS pandemic in sub-Saharan Africa have varied considerably. At one end of the spectrum lie responses based on faith — either traditional Christian or Islamic values of sexual morality or in similarly traditional African medicine (Chapter 5), all of which can be at odds with the Western biomedical approach. Largely successful efforts by Western governments to counter the spread of HIV/AIDS amongst homosexual populations in the US and Europe have tended to focus on the disease as a medical issue. Efforts have concentrated on interventions that reduce the chance of exposure by those most at risk of contracting HIV/ AIDS. Campaigns centring on the use of condoms and ‘safer-sex’ have been hallmarks of such drives. However, as the rampant spread of HIV/ AIDS during the past three decades attests, the safer-sex approach has been notably less successful in sub-Saharan Africa, prompting calls for a re-examination of the safer-sex model’s suitability for the region. In particular, Christian faith-based organizations (FBOs) have long pressed for an alternative approach based on a focus on behavioural change, in effect a ‘social vaccine’.

Policymaking, Dissidents and Denialists

HIV/AIDS ‘dissidents’ have been compared with Holocaust deniers, to the point where there have been calls for them to be prosecuted in the manner of David Irving, the British historian jailed in Austria in 2006 for maintaining, amongst other problematic points, that there were no gas chambers at Auschwitz (Smyth 2006). The terms AIDS ‘dissident’ or ‘sceptic’ cover a broad spectrum of opinion. Dissidents are by no means unified. Different individuals and groups have made various claims about the nature of HIV, the link between HIV and AIDS, and the efficacy of antiretroviral treatments. Some have questioned whether AIDS as a disease exists at all. The majority of dissidents base their theories on what are perceived to be ‘holes’ in the science underpinning HIV/AIDS ‘orthodoxy’. For analysts and policymakers, the question at the heart of the debate is one of censorship. Should dissidents, in the interests of freedom of speech and scientific inquiry, be permitted a platform for their views? After all, in the best traditions of liberalism, and in the spirit of John Stuart Mill (1998), any theory, if ‘true’, should be able to withstand scrutiny.