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The struggle for social justice is deeply woven into the fight against AIDS—and will likely continue long after AIDS has faded.

At the XVII International AIDS Conference, held in Mexico City this summer, a new drama debuted over the long-term direction of the fight against AIDS. The battle is portrayed in the health policy arena as vertical programs that treat HIV in isolation from the general health environment pitted against horizontal programs that seek to strengthen countries’ overall health systems. But the real struggle may be over how the vast amounts of money now given for AIDS relief are channeled, with vertical money going to health ministries, NGOs, and programs, and horizontal money going directly to central treasuries. Obviously, those holding power in governments prefer the latter, while AIDS activists say it would be foolish to abandon a plan that is working, and that a “diagonal” approach to extend the success in AIDS to the rest of society is a better idea. But the issue may no longer be what is best for health. With annual AIDS dollars now in the tens of billions and climbing, powerful interests may be encroaching on health policy as the money increasingly looks like “foreign aid,” which has historically been used to buy influence and gain hegemony in the political world.

At past conferences, battles were fought over prevention versus treatment as public health experts debated which approach should have precedence in controlling the AIDS pandemic. With treatment now proven successful and PEPFAR funding secure for a few more years, prevention joined treatment on the stage in Mexico without crowding, and the time seemed right for a grand alliance. Treatment reduces fear and stigma and increases the likelihood of testing. It reduces viral load and the likelihood of transmitting HIV. And treatment is becoming a cornerstone of prevention now that expectations for technology have been cooled by setbacks in vaccine and microbicide research. Meanwhile, proven prevention interventions like circumcision have been slow to take off and promising preexposure prophylaxis trials stumble forward. The field is overdue for a renaissance in behavioral prevention research, which had been severely limited by funding restrictions during the U.S. conservative surge of the past eight years.

Human rights and the visibility of marginalized behaviors (sex work, homosexuality, and drug use) were central to this conference. The organizers deliberately shift focus every two years to bring contentious and previously underrepresented perspectives into the foreground, though some attendees complained that emphasis on women and on the African epidemic had been shuttled from the stage too soon. A new realism about “risk” behaviors was also evident, with a growing understanding that there are underlying emotional dimensions to what people do and prevention approaches that address rational choice alone fail to have lasting impact.

With release of the CDC’s increased U.S. HIV incidence estimate, attention also turned to prevention in the United States. There was something disingenuous about the alarm expressed over the 40% higher number, however, as if the old estimate of 40,000 new infections per year did not warrant a determined response. Yet during the Bush administration—when serious prevention research addressing sex workers, MSM, drug users, and gay youth was essentially taboo—the prevention infrastructure became fractured and progress stopped. Frustrated by restrictions and a climate of fear, much of the creative and energetic prevention talent drifted away from AIDS service organizations, leaving prevention programs in the hands of administrators and timid leaders where they languished.

If one steps back from the medical aspects of AIDS just a little, the vast background of social injustice is not hard to see. In Mexico, social issues were discussed with much less abstraction and greater realism than at prior conferences. On the legal and human rights fronts, the threats of criminalization were in the spotlight and there was recognition that social change does not always move in a progressive direction. So-called model laws that punish transmission of HIV are spreading in Africa and elsewhere. These laws threaten to increase stigma and inhibit testing and treatment, while visiting unjust and disproportionate retribution on a few, highly vulnerable individuals. Criminalization only seems rational in an environment of ignorance and fear and must be opposed with plain-speaking leadership at the highest levels.

A revolution in culture and society cannot be counted upon to solve the HIV crisis, however, and this is why interest in the medical and scientific progress continues to overshadow the attention and money given to social and behavioral interventions. Transformations caused by ideas alone are rare in history, but revolutions introduced by technology are common—and cultural changes follow in their wake. Effective new technologies like gunpowder, penicillin or cell phones, whether destructive, lifesaving or merely convenient, spread quickly and tend to erase the memory of what life was like before their appearance. For AIDS, a single, cheap, nontoxic, and highly effective antiretroviral pill would make achieving universal access to HIV treatment much more likely. An effective, one-shot, preventive vaccine could, over time, reduce the HIV conflagration to smoldering embers, removed from the public consciousness, much as polio is today.

The XVII International AIDS Conference in Mexico City may have displayed a more mature understanding of the social dimensions of HIV, but the struggle to incrementally improve the lives of the millions affected will be slow, even if a transforming HIV technology emerges. Unfortunately, no such technology was revealed in Mexico City.

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