Time to Rethink Global HIV/AIDS Care

By Nicole Itano

After 13 years at the head of the UN’s AIDS organization, Dr. Peter Piot is stepping down. His departure offers an opportunity; a chance for a new generation of leaders to shake up the hidebound world of AIDS advocacy and international aid.

A Belgian microbiologist who contributed to some of the first studies of AIDS in Africa in the early 1980s, Piot has been around since the beginning of the fight. He deserves credit for helping to bring the African epidemic to international attention, for marshalling billions of dollars of international aid and for overseeing the rollout of treatment for millions of people who would otherwise have been condemned to a slow and painful death.

But more than a quarter of a century into the epidemic, we’re desperately in need of new ideas. The AIDS world has been trapped in an outmoded paradigm, defined by a set of decades-old assumptions forged in the first-world and imposed on the developing world.

Despite all our efforts, we’re still losing the fight. By the UN’s own estimates, there were 2.5 million new infections last year. Part of the reason the virus keeps spreading is that we keep using the same old techniques, even when we know they don’t work. AIDS is a complex and multi-faceted epidemic, yet we’ve responded with one-size-fits-all solutions.

We need to start questioning some of our basic assumptions about the epidemic: that testing can never be compelled, that a person’s HIV-status is a private affair, that stigma is the dominant social experience of the infected, and that condoms are the best protection against the virus.

On the frontlines of the epidemic, especially among Africans themselves, many of these unassailable truths have been slowly crumbling. Across the continent, I encountered deep frustration on the part of medical professionals and local activists who felt the global dialogue about AIDS was out of step with the realities of their own communities. They felt constrained from taking innovative action by the rules of the AIDS world, even when they felt those rules were entirely culturally inappropriate.

Many African doctors, for example, believe the western emphasis on privacy in relation to AIDS has actually increased, rather than reduced, stigma by making AIDS more frightening than other diseases. Yet most AIDS testing still takes place in special clinics, separate from general health care. Most of the women I met had little faith in condoms; they wanted their men to stay faithful. Yet the vast majority of prevention programs still focus on condoms. These messages aren’t filtering up to the top, where AIDS agendas are being set.

This changing of the guard offers a chance for fresh thinking and, hopefully, radical new action.

Nicole Itano is the author of “No Place Left to Bury the Dead: Denial, Despair, and Hope in the Africa AIDS Pandemic,” published by Atria Books and reviewed by Eleanor Bader in this edition of On The Issues Magazine .


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Merle Hoffman's Choices: A Post-Roe Abortion Rights Manifesto

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“Merle Hoffman has always known that in a democracy, we each have decision-making power over the fate of our own bodies. She is a national hero for us all.” ​—Gloria Steinem

In the wake of the Supreme Court overturning Roe V. Wade and a country divided, a pioneer in the pro-choice movement and women’s healthcare offers an unapologetic and authoritative take on abortion—“the front line and the bottom line of women’s freedom and liberty.”

Merle Hoffman has been at the forefront of the reproductive freedom movement since the 1970s. Three years before the Supreme Court legalized abortion through Roe v. Wade, she helped to establish one of the United States’ first abortion centers in Flushing, Queens, and later went on to found Choices, one of the nation’s largest and most comprehensive women’s medical facilities. For the last five decades, Hoffman has been a steadfast warrior and fierce advocate for every woman’s right to choose when and whether or not to be a mother.