By David Kault
AIDS in Australia is a particular threat to stigmatised minority groups such as homosexuals, drug addicts and prostitutes. The spread of AIDS amongst people in these groups occurs largely as a result of acts occurring in private, where government regulations cannot easily reach. In recent times attitudes towards people in these groups have softened and, appropriately, there is in some quarters now a sense of guilt about the way they have been treated.
It is against this background that the established philosophy of AIDS control has evolved. This philosophy emphasises the need to gain the confidence of minority groups by strictly respecting privacy and rejecting authoritarian methods. Intervention takes the form of assisting the group to mount a campaign to educate group members on risky activities and modify behaviour within the group accordingly.
Although this public health philosophy seems to be an appropriate match to the social background of the disease, it does not necessarily follow that the current approach is the best method of limiting the spread of AIDS.
Confidence building and group education alone may not change behaviour sufficiently to prevent the continuing spread of the disease. There is evidence that the effectiveness of the current Australian AIDS control strategy has been over rated and that more authoritarian methods of AIDS control would be more effective.
Ideology
Unfortunately, it seems that the current AIDS prevention strategy has been chosen purely because of its ideological correctness. People of undoubted good will like the late Professor Fred Hollows, who have suggested other strategies, are berated because their strategies are ideologically unacceptable.
Hollows labelled his opponents the "AIDS establishment". This establishment smugly asserts that Australia is doing better than anywhere else in the world with AIDS. The truth or otherwise of this assertion is the most important issue here, but it is worth looking in more detail at the ideology.
The ideology underlying the current strategy favours individual and community education rather than state intervention. This sits nicely with a belief in individual freedoms and responsibilities as opposed to state responsibility for public welfare. In other words, current AIDS strategies are rooted in liberalism, the each to his/her own philosophy that justifies the capitalist system and spares the state the expensive responsibility of protecting individuals who are unable to act in their own interest. Liberalism is an unrealistic and self-contradictory philosophy.
The need for organised cooperation in the form of state regulation had long been recognised in the area of public health despite the dominance of liberalism in economic life. Infectious diseases behave as though humans live in a society, not as though they are a series of unconnected individuals. Therefore, from ancient times densely populated states have regulated individuals in the interest of public health with laws regarding sewerage disposal and isolation of people with serious infectious diseases. This traditional approach to public health by state regulation has been reversed in the case of AIDS. Why has this occurred?
Over the last 40-50 years the traditional role of public health diminished as infectious diseases in rich countries were largely eliminated with the advent of antibiotics and vaccines. As mortality from infectious diseases declined, mortality from heart disease, cancer and car accidents climbed. These are a direct consequence of unhealthy approaches to consumption, work, transport and environmental pollution engendered by the capitalist system.
However, public health could not be allowed to blame the capitalist system for the new major health problems; instead health problems were ascribed to lifestyle choices by individuals, and the need for individual responsibility in health was emphasised.
Such analyses overlook the social pressure behind an unhealthy choice and allow capitalists to continue to make profits out of people's unhealthy choices. Even in the most extreme cases such as cigarette smoking, attention was focused on encouraging individuals to stop rather than on cigarette advertising. Eating habits are dictated by advertisers and producers; rather than encourage regulation of the food industry to take into account long-term health effects, public health urges individuals to make healthy choices about food. Instead of urging the government to provide safer public transport rather than private transport, the new public health deals with car accidents, the major killer of young people, by ineffectual "drive to stay alive" campaigns directed at individuals.
Similarly, with the advent of AIDS in 1981, public health took a different approach than it had to all previous infectious disease. Rather than compulsory screening, isolation and treatment, which had been used for all serious infectious diseases until TB ceased to be a major problem about 20 years ago, a new liberal approach was adopted.
The liberal approach appealed to minority groups at risk, who had long been victims of authoritarianism. Likewise it appealed to progressive political parties that supported gay rights. It appealed to those already infected. Presumably, it appealed to some decision makers who may not have been interested in taking any strenuous measures to protect the lives of those at risk. But the important question remains: is this liberal approach effective?
How effective?
There is evidence that the current approach has had some success. There is firm evidence that needle exchange programs have slowed the spread of AIDS amongst drug users. There is also good evidence of increased usage of condoms by prostitutes. Several Australian surveys have shown that a considerable number of gay men now generally practise "safe sex". Gonorrhoea in gay communities has declined dramatically. Data on the number of new cases of HIV infection is hard to come by because of privacy considerations, but a method of mathematical analysis known as back calculation has shown that the number of new cases reached a peak in the mid-1980s, and the incidence now is perhaps a fifth of the incidence then.
But holes appear on closer inspection. Most importantly, back calculation and evidence from continuous monitoring of gay men suggests that at least 600 gay men in Australia are still becoming infected each year. This will make AIDS the commonest killer of young people after car accidents.
Moreover, neither the decline in new cases of HIV infection nor the decline in gonorrhoea necessarily indicate increasing success for HIV prevention strategies. My own work has shown that these apparent indicators may be misleading. Gonorrhoea will decline dramatically in an AIDS epidemic regardless of behavioural change simply because those first incapacitated by AIDS are likely to have been those who accounted for most of the spread of gonorrhoea.
The decline in the incidence of new cases can also be explained by the epidemic passing its natural peak. Epidemics naturally peak simply because the numbers who remain susceptible start to thin out. In the case of HIV, it is likely that the virus spread very quickly through a relatively small core of people with very high partner change rates and since then the epidemic has been smouldering along, slowly infecting newly active gay men and those with lower partner change rates.
The direct survey evidence on behavioural change in the gay community is also less than impressive. When infected people have been surveyed in Australia, appreciable numbers openly admit to continuing unsafe behaviour. An American study has shown that people who were aware that they were HIV-positive were as likely as HIV-negative people to become infected with another sexually transmitted disease.
Overall condom sales have not greatly increased, suggesting there has been little behavioural change in the heterosexual population. Moreover, while "safe sex" is safer, evidence from a number of overseas studies on condoms and HIV shows that it may not be safe enough.
A further problem is that the current approach prevents more accurate assessment of its own success or otherwise. The figure of 600 newly infected gay men each year is a rough estimate. Privacy considerations preclude the more extensive screening necessary to firm up this figure, and estimates rely on very incomplete information complemented by mathematical analyses.
The situation is much worse as regards information about people outside the traditional risk groups, since they are not tested in sufficient numbers. There is some screening of soldiers, prisoners, blood donors and some people with sexually transmitted diseases, as well as sporadic testing of concerned people.
This screening is enough to show that there is not yet a large HIV problem outside the traditional risk groups. However, for various reasons the samples tested are likely to be biased and the numbers tested are not sufficiently large. Therefore this screening is unable to give early warning of an emerging epidemic in various sub91×ÔÅÄÂÛ̳ of the population.
Alternative policies
If the liberal approach to AIDS control has been oversold, what evidence is there for the likely success of alternative policies? The evidence is limited because a liberal approach has been almost universally adopted throughout the developed world and few countries have tried alternative approaches. There are two notable exceptions.
Sweden isolates HIV-positive people "suspected" of recklessly or intentionally spreading the virus, and it has an intensive contact tracing program. According to the World Health Organisation, Sweden has about half Australia's incidence of AIDS.
The case of Cuba is more dramatic. Cuba has every reason to have a horrendous AIDS problem. It had a huge military presence in Africa, one of the centres of the AIDS epidemic, and military activity is closely correlated with the spread of AIDS. Cuba is located close to another centre of the AIDS epidemic, Haiti. Cuba is a relatively poor country trying to create a tourist industry — a feature that in other places is associated with a high incidence of AIDS.
However, socialist Cuba has deviated the most from liberal AIDS policies. It screens all those whom it suspects may be HIV-positive and quarantines all those who are positive. The outcome is that Cuba, on a per capita basis, has had about one-thirteenth as many AIDS cases as Australia.
A few international comparisons cannot give conclusive evidence. A lower incidence of AIDS in any country could simply reflect differences in culture and differences in the time since AIDS was introduced. There is, however, evidence for the effectiveness of authoritarian methods in preventing other infectious disease.
Historically, authoritarian measures have been used to prevent infectious disease from ancient times until TB control programs petered out in the 1960s. This long usage over times when infectious disease was very common suggests that these measures worked. By contrast the current strategy has evolved in an era in which infectious diseases other than AIDS are rare.
Even in Australia today, very harsh authoritarian measures are enthusiastically applied to the spread of infectious disease when the disease poses a major economic threat, as is the case for exotic livestock diseases. The arguments used in the case of AIDS — that authoritarian measures drive people underground and so promote disease spread — could also be applied to farmers with stock carrying a serious infectious disease. Where a disease is a threat to the economy rather than people, it seems to be assumed that authoritarian methods are more effective.
My assessment is that the evidence strongly suggests that the liberals are wrong. A more traditional and authoritarian public health approach is likely to be more effective in limiting the spread of AIDS. The community then needs to balance the likelihood that a more authoritarian approach would save lives against the cost in terms of civil liberties.
However, I believe that the Cuban approach of physical quarantine is not necessary for those who are clearly willing to sexually quarantine themselves from the uninfected population. I would advocate a program of universal screening and thorough contact tracing, with severe penalties and permanent isolation for those knowingly spreading the disease to uninformed sexual partners. Such a policy implies a cost to HIV-positive individuals. Since individuals would be expected to bear this cost in the interest of the wider community, they should be compensated both financially and by the continued enforcement of anti-discrimination laws. An HIV pension would be appropriate.
There would of course be many problems with such a policy: people evading screening, complacency amongst those who test negative, false positive and negative HIV tests. Despite these problems, the evidence indicates that such an approach is likely to save more lives.
It is clear that there are no wise experts who can make a definitive statement weighing up civil liberties concerns and the likely effectiveness of possible AIDS prevention programs. The evidence should be assessed by the community and decisions should be made which reflect the likely effectiveness of the prevention program as well as diverse views on ideology and ethics. It is unacceptable for the AIDS program to be simply pronounced effective because it accords with the ruling ideology. [The author is a medical doctor and mathematician who has been working on mathematical models of the AIDS epidemic for the past three years. The views expressed do not necessarily reflect the views of his employer or funding body.]