On the heels of an exciting announcement of a breakthrough in the battle against AIDS, it’s important to consider the social and community-level influences that will be at play once the controlled conditions of scientific trials have faded away. AIDS is a community-level phenomenon. Though it is individuals who pass HIV to their partners, the degree to which any person’s behavior puts them at risk for contracting HIV is in part attributable to the amount of virus in all HIV-positive people in a community, or “community viral load” . Community and cultural influences play a large part in whether practices will be adopted, so it is significant that this breakthrough was found in a multi-nation study in natural settings. However, what this study did not take account is what may be the biggest barrier to global benefit from this breakthrough: economic inequality.
Since highly active antiretroviral therapies (HAART) became available for the treatment of HIV/AIDS, mortality rates from this disease have decreased dramatically. However, these benefits have not been distributed evenly. For instance, in Hawai‘i where I live, diagnoses of AIDS have been decreasing over the last decade, and AIDS-related deaths decreased sharply in 1996 and the years immediately following it, coinciding with the widespread use of HAART. However, the decreases in AIDS-related mortality have not affected all groups similarly. Prior to 1996, the proportion of deaths due to AIDS for different groups were similar to the proportion of people living with AIDS. After 1996 this changed, with Caucasians comprising a relatively smaller proportion, and Native Hawaiians and Pacific Islanders comprising a much larger proportion of those dying of AIDS in the 5 years after the introduction of HAART compared with both their previous mortality rates and the proportion of those living with AIDS. This may be due to a number of factors, but economic disparities surely play a role, as the treatments for HIV/AIDS can be extremely expensive.
Across the globe, there has been debate about whether and to what extent countries and organizations should provide funds for HIV/AIDS treatment. Some of the debate is in regard to whether prevention or treatment should be prioritized. Fortunately, this breakthrough diminishes this dilemma, as it involves using “treatment as prevention.” Those same antiretrovirals that help treat those with the disease decrease the viral load and make it less likely that a person infected with HIV will pass on the virus. This has long been suspected, but this trial is the first large-scale study to truly investigate whether the timing of antiretroviral treatment affects transmission. HIV-positive persons with HIV-negative partners were assigned to either begin receiving antiretroviral treatment right away or to wait until their disease had progressed further. Those who began taking antiretroviral drugs right away were 96.3% less likely to pass it on to their partner. In addition to reducing transmission, early retroviral therapy improved outcomes for the HIV positive partner. As scientific advances transform the AIDS epidemic, issues of social justice increasingly come to the forefront, as treatment continues to be more available to the economically advantaged. As community psychologists, we can work to ensure that these issues are discussed, and to remind people that decreasing community viral load means decreasing risk for all people.
Gina Cardazone, University of Hawai`i, Mānoa