110 AIDS, sociology of

approximately 5 percent of those who are
infected are currently receiving the most effec
tive therapy. Prospects for access to treat
ments continue to be thwarted by poverty
and global inequalities despite the recent
moves for treatment access for all: the Glo
bal Funds commitment to buy and distribute
cheap generic drugs to poor countries; and the
3 by 5 initiative of the World Health Orga
nization (WHO) to provide ART therapy to 3
million people by 2005. To the middle of
2004, only 400,000 of the 3 million had been
treated with ART.
The 3 by 5 initiative, although welcomed
by many, has placed an additional burden on
much of the developing world the burden to
test their populations. There are estimates that
between 180 million and 300 million people
will need to be HIV tested at least once in
order to reach the target of 3 million people
on ART. People have been slow to come for
ward for testing, however, because of the
stigma and discrimination often associated
with an HIV positive diagnosis. As a result
of the poor response, routine opt out test
ing is being adopted in countries with high
prevalence rates. While some interpret this
response as necessary, others are concerned
that the pressure to test will undermine
human rights and increase stigma and discri
mination rather than reduce it.
An added incentive to treatment rollout is
the possibility that if treatment uptake is
extensive, then ART may also act in a pre
ventive fashion. It is yet to be proven whether
widespread testing and subsequent uptake of
treatment among those who are HIV infected
will reduce the population viral load and
hence make HIV transmission less likely. In
the developed world, high uptake of treatment
has not led at least not initially to a
reduction in HIV transmission. In some coun
tries such as the United States and Australia,
treatment uptake is related to a relaxation in
safe sex and an apparent concomitant
increase in HIV incidence.
The current push for routine testing and
treatment carries with it the risk of downplay
ing prevention. In recognition of this problem,
some are advocating prevention in the clinic
voluntary counseling and testing have become
a site for prevention. While prevention in the
clinic may be a useful addendum to health
promotion, it is unlikely to succeed alone.
What is needed to sustain changes in sexual
and drug injection practice is cultural and
normative authority, and such authority is best
achieved in the social realm. The clinic is by
its very nature private, confidential, and indi
vidualistic and thus unlikely to provide the
appropriate environment for sustained preven
tion. More importantly perhaps most impor
tantly extending testing so as to make it a
major prevention tool will give governments
the excuse to draw back from HIV, the excuse
not to have to deal with and face the complex
ities of talking about sex and drugs, the excuse
not to train teachers and those in contact with
the young, to raise issues in connection with
HIV transmission. It will excise the public and
collective voice.
The current conservative global climate
appears to be producing a flight from beha
vioral prevention. While it is imperative that
the quest continue for a cure to HIV and
AIDS and for an effective prophylactic vac
cine and other prevention technologies, it is
equally vital that such endeavors do not
undermine the gains already made. The chal
lenge for modern public health is to address
the social, cultural, and economic dimensions
of health, to address issues of power between
and within countries, and to attack discrimina
tion and prejudice.

SEE ALSO: Drug Use; Gender, Development
and; Globalization, Sexuality and; Health Risk
Behavior; HIV/AIDS and Population; Human
Rights; Prevention, Intervention; Safer Sex


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