Neoliberal Globalization, Inequality, and HIV

The growing impact of AIDS coincided in the West with reductions in public sector institutions and their replacement with private ones. These so-called neoliberal governance strategies set conditions for foreign aid and shaped guidelines for liberalizing economies in the developing world. They also created the conditions for economic globalization.

In response, governments in many parts of the world scaled back their public sectors, limited funding for education and health care and required people to pay user fees to access them. These forces gave rise to a proliferation of nongovernmental organizations in many places. In these ways, the forces of globalization that were supposed to liberalize the economies around the world fanned the spread of HIV and hampered its control.

A 1990 ACT UP demonstration at the National Institutes of Health demanding more research on AIDS (top left). ACT UP demonstrators at the first Fresno Lesbian-Gay Pride Parade in 1991 (top right). ACT UP and Occupy Wall Street protestors in 2012 demanding a tax on Wall Street to fund global AIDS treatment, prevention, and care (bottom left). An ACT UP protester at the ACT UP 30th Anniversary Gathering Rally in 2017 (bottom right).

In the United States, gay men and their allies founded protest groups and non-governmental organizations to try to address the disease. The AIDS Coalition to Unleash Power (ACT UP) used in-your-face tactics to shame officials and researchers. They occupied the New York Stock Exchange and threw human ashes on the White House lawn. The Gay Men’s Health Crisis in New York strove to take care of people living with AIDS. These organizations did what elected representatives and the medical profession were not doing adequately: sticking up for and looking out for those at risk for contracting HIV and those who had AIDS.

The AIDS crisis of the 1980s was not just an American and Western European problem, however. Sub-Saharan Africa, we now know, was the birthplace of the disease and has been the region most devastated by it. The virus had spread silently to eastern Africa in the 1970s and eventually went south.

The Great Lakes region of Africa (left). A 2005 sign from Dar-es-Salaam, Tanzania promoting AIDS awareness (right).

If the early North American epidemic was predominantly among gay men, the African outbreak was overwhelmingly heterosexual. While the disease had traveled down the Congo River to Leopoldville and Brazzaville, the highest rates of infection in the 1980s were in the Great Lakes region, with rapidly growing rates of infection in Burundi, Rwanda, and Uganda.

Trade and transport networks within the region also spread the disease to Kenya and Tanzania, and by the end of the decade the disease had pooled at the bottom of the continent, with South Africa’s prevalence rates rising while Lesotho and Swaziland’s number of AIDS cases ballooned. In 1989, 1.2% of Swaziland’s adult population were HIV positive. A decade later, 20.6% of adults had the virus.

A 2011 map of estimated HIV infection rates in Africa.

Structural adjustment programs and conditional aid from the West required economic concessions and rollbacks of government services. Thus in Africa, as in the United States, non-governmental organizations like Uganda’s The AIDS Support Organization (TASO) tried to fill the gaps between families and shrinking health care systems.

As a consequence, there were no drugs for treatment in Africa, and with a six- to ten-year incubation period, the disease scythed the middle-aged populations. After families devoted time and resources to nurse those affected and to ease their path to death, the orphans and grandparents had to reconstitute families and restructure society.

AIDS Science and the Global Health System

World Health Organization logo commemorating the eradication of smallpox in 1979.

AIDS emerged on the global stage at a moment of great confidence in the World Health Organization and the promise of global health. When doctors, scientists, and public health officials described the disease that came to be known as Acquired Immune Deficiency Syndrome in 1981, they had just eliminated smallpox in 1979. The end of smallpox remains one of the greatest successes in the history of the human battle with infectious disease.

The devastation and mystery of AIDS undercut decades of global public health success, however, and derailed a push for worldwide primary care. AIDS challenged both the global health system and scientific understandings of disease.

Molecular biologists and virologists raced to figure out a disease that defied the central dogma of cellular biology: that DNA encodes RNA and RNA encodes the proteins. HIV, a retrovirus, upended this scientific consensus.

Robert Gallo in the Laboratory of Tumor Cell Biology at the National Institutes of Health.

Retroviruses are an unusual class of viruses that Howard Temin identified in the 1960s. His findings, however, were initially ridiculed, and only took hold in the early 1970s. Thus the study of retroviruses was still in its infancy when AIDS began to dominate headlines. Robert Gallo discovered the first human retroviruses in 1980, and his lab in the United States and Luc Montagnier’s lab in France first identified HIV as a retrovirus in 1984.

Pharmacologists and immunologists had to figure out how to stop a retrovirus. The first partially effective pharmaceutical answer to HIV arrived in 1987. Azidothymidine (AZT) slowed the effects of HIV but it was extremely expensive and available only in western countries. Those who could afford the doses found out that AZT’s effectiveness declined over time as the virus developed resistance.

The answer to treating HIV lay in combination therapies. Scientists created many new drugs in a surprisingly short amount of time. By the mid-1990s, patients who received “cocktails” of three antiretroviral drugs saw their viral loads shrink and their immune systems return. Patients who had been on death’s door returned to life in a matter of weeks.

Combination therapies could save millions of lives, but they were too expensive for most patients to afford. Pharmaceutical companies held the patents for these drugs and new global regulations allowed them, not public sector organizations, to set the prices.

A protester at the 30th Anniversary Gathering Rally NYC AIDS Memorial in 2017.

Member states of the World Trade Organization approved the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) in 1994 to codify a global standard for protecting intellectual property rights. These rights included patent protection for pharmaceutical companies.

Street art in South Africa from 2008 appealing for men to not rape children. Many falsely believed that raping a virgin would cure AIDS.

The most prominent conflict between public health and intellectual property took place in South Africa. The inequality of apartheid had helped HIV gain a firm foothold in the country in the early 1990s, and by the end of the decade more than 20% of South Africans were infected. South Africa held its first fully democratic, multiracial elections in 1994 and had one of the continent’s strongest economies. But with average annual incomes at $2,600, most HIV-positive people could never afford the yearly cost of $12,000 for antiretroviral drugs.

The government of South Africa changed its laws in 1997 to allow it to seek better drug pricing. This set up a showdown with the Pharmaceutical Research and Manufacturers of America (PhRMA), who threatened to sue South Africa over TRIPS violations of intellectual property. A globalizing economy had spread HIV, and rules to protect the global economic system stood in the way of life-saving drugs for millions of South Africans.

While many South Africans had been dissatisfied with their government’s approach to HIV, even its harshest critics, like the Treatment Action Campaign, lined up behind the South African government. The optics of the lobbying arm of a multi-billion-dollar industry suing the country with the largest population of HIV-positive people reflected poorly on PhRMA. They dropped their suit and negotiated a way for people in the global south to obtain antiretrovirals.

Attendees, including South African President Cyril Ramaphosa, at the Sixth Annual Congress of the Treatment Action Campaign in 2017.

Private foundations became part of the solution too. The Clinton Foundation helped broker drug manufacturing deals and offset drug costs. The Bill and Melinda Gates Foundation was an early, prominent donor to the Global Fund.

The Present and Future of HIV

Where global efforts fell short in stemming the virus early on, the pharmaceutical advancements and global agenda in the past decade, by taking on a more systematic approach, have made enormous advancements in treatment.

Combination therapies can be cheaply produced in a single pill, and a two-drug combination of emtricitabine and tenofovir (marketed as Truvada) was approved in 2012 as pre-exposure prophylaxis. People at high risk of HIV infection can take it daily to protect themselves from the disease.

Archbishop Desmond Tutu getting an HIV test as part of his foundation’s mobile test unit (left). A midwife in Uganda drawing a patient’s blood using a machine provided by USAID in 2012 (right).

Patients who adhere to their antiretroviral treatments can reduce their viral load of HIV to undetectable levels. With this is a growing consensus that undetectable levels mean the virus is not transmissible. This makes HIV a chronic condition to be managed for those with access to antiretrovirals.

These advancements parallel a bold goal in global HIV prevention and treatment. In 2013, UNAIDS and its partners made a plan for 2020. By then they want 90% of all people living with HIV to know their status; for 90% of those diagnosed with HIV to receive antiretroviral therapy; and for 90% of those on treatment to achieve viral suppression.

Interactive map and chart of the share of the population infected with HIV as of 2016 (Institute for Health Metrics and Evaluation and Our World in Data).

For some countries, this 90-90-90 goal is attainable. In the central African nation of Malawi, 90% of people living with HIV are diagnosed, 79% of those are on antiretrovirals, and 87% of them are virally suppressed.

The key to these successes has been a shift in the practice and funding of global health. UNAIDS, PEPFAR, and the Global Fund have realized that without robust health systems in place, HIV prevention and treatment will stall. Thus, while the WHO’s old goal of primary health care for all fell to the wayside with the advent of AIDS, the new model of treatment and prevention recognizes the importance of healthcare infrastructure. Massive investments in drug provision and health systems aim to halt new infections worldwide.

In eastern Europe and central Asia, however, the numbers of new infections and AIDS-related deaths are still on the rise. Russia reported in 2017 that 81% of people living with HIV in the federation knew their status, 45% of those were on antiretrovirals, and 75% of those in treatment were virally suppressed. For the 19% of those who are undiagnosed, and the 55% of those diagnosed but untreated, the possibility of spreading the disease remains high. HIV/AIDS rates in China have surged in recent years, increasing by 14% with 40,000 new cases in the second quarter of 2018.

Treatment Action Campaign activists during a 2003 march on South Africa’s parliament (left). A 2006 outreach session about HIV/AIDS in Angola (right).

So when we look back at a century of HIV, we see a virus that has ridden the wave of globalization, spreading with colonial structures and using the disruptions of decolonization and the Cold War to jump the Atlantic. Neoliberal globalization at the end of the twentieth century created a world open for investors but those same conditions failed to check the virus.

As we look ahead past this century of HIV, it is hard to know which global forces will most shape the virus’s evolution. The current successes in treatment and prevention hinge on tremendous financial contributions from a few countries. As populism sweeps the globe, will these countries remain willing to shoulder the cost of arresting HIV?

President Barack Obama at George Washington University on World AIDS Day in 2011 (Photo by Lawrence Jackson).

In 2017, when a clinical officer in rural Malawi contemplated the possible loss of PEPFAR funding, he could anticipate only one outcome. “Many people will die,” he said, and repeated, “Many people will die.”

For now, however, we can reflect on this World AIDS Day that there are more people living with HIV than have died from the disease, and the number of those living positively goes up every day.

Read more from Origins on disease and human health:  The 1918 Flu PandemicTop Ten Origins: FluAmerica's Long-Suffering Mental Health SystemInfluenza Pandemics Now, Then, and AgainFood and ChernobylFluoride ; VaccinesTop Ten Origins: Vaccination.