Thirty whole years have passed since the discovery of HIV. A serious infection that, left untreated, becomes fatal. During those 30 years, as the epidemic took more and more lives, clinical research worked desperately to counter it. Yet to this day we are still losing people to it, and those whose lives are prolonged by biological interventions are still suffering under the state of health-services which are, in many cases, health-damaging rather than health-promoting. Why? Because if we are to take HIV seriously, then every action taken towards countering it must address the individual as a whole person.
We know that HIV doesn’t just affect physical health, it damages behavioural and mental health too. But sadly, all we ever hear about are biological successes in countering the epidemic, not behavioural or psychological treatment interventions. Clinical experts should be equally available to treat the behavioural and psychological health of a patient. Because in fact, what the eye cannot see is far more challenging because we are dealing with a subjective experience, not just the objective marks of the disease – so a physician, for example, would not be sufficient enough to intervene. We have to rely on the level of insight a physician has, in order for them to refer the patient to an expert in behavioural or psychological health. In no circumstance should the patient ever be given a pill on its own because illness isn’t just about the body. Also, in contrast to medication, mental treatments can never be reduced to a pill. Yes, a pill may alter some wires here and there, but really – like I said before – we’re dealing here with people and people are complex.
Put simply, a medication not does address an individual’s behaviour or the motivations for it. So, while antiretroviral therapy (ART) may have transformed what was once a death sentence into a manageable disease and reduced HIV transmission worldwide, it hasn’t stopped it; the pandemic is still expanding. And no, a ‘cure’ is not the immediate answer! See, there’s a trend here: just like a pill isn’t the immediate answer, neither is a cure.
We know ART prolongs life in most cases, but it is simply not cost-effective to keep using it and viewing it as the only solution. The costs are increasing for many organisations and public health systems and HIV is just one exemplar of this situation. Logically, the focus should shift from ‘cure’ to prevention and to making the most of what we have already. Because when used, behavioural and social interventions save a lot of money for public health systems, and they help prevent HIV transmission too. Alternatives to relying solely on medications for HIV are desperately needed in order to benefit patients at manageable costs. An integrated model of services that centres around the whole patient really is the most logical solution, as it will produce the best possible health-outcomes. Ultimately, it’s where we will save costs.
Prevention should also definitely become a priority. When I first read about the International AIDS Society (IAS) conference that was held back in July, I just couldn’t believe how much of the focus was put upon ‘finding a cure’. As if it’s going to happen any time soon, as if pharmaceutical companies aren’t still trying to tackle the complexity of the infection.
But, surely, preventing the infection reduces the need to eradicate it – so why isn’t prevention a priority? Not enough is being done to prevent the infection spreading in the first place, and a significant part of a needed solution is already clear – biopsychosocial medicine, or the integration of biological, psychological and social health-services for people with known risks for HIV. Clinical services provided specifically for behavioural and social health should overlap with public health services.
It seems like ‘prevention’ just doesn’t live up to the glamour of ‘cure’ which is so very popular in the public’s imagination. And why should it? It’s not going to interest anyone who wants to make a quick profit, is it? Well, the question that springs to my mind is: what about the patients? A far-off cure is much less pretty to those who already have the advanced stages of the infection, and have suffered enough. No, I’m sure they would appreciate better quality health-services that address their every need in order that they get better, feel better, and stay better.
Every clinician possesses an ethical duty to help patients acquire the skills and personal resources they need to practice health-promoting behaviour. If they don’t have those skills themselves, by being a psychologist for example, it’s their ethical duty to ensure that a psychologist is available. If they don’t offer their help in this way, how are patients to acquire the knowledge and skills to head for health? This is the reason integrated services are necessary; a physician is there to offer medication, but without collaborating with psychological and behavioural experts to treat those aspects of health, they aren’t empowering patients to change particular behaviours where they are most clearly needed. For instance, the prevention-targeted groups of men who have sex with men (MSM) and young adults.
Now, while it is essentially the patient’s responsibility first and foremost, we can’t criticise people for not having the inner resources to engage in health-promoting behaviours unless they have been provided the best circumstances in which to acquire them – like simply being referred to a behavioural specialist. So it’s fair to say that it’s the clinician’s ethical responsibility first.
And then there’s the darker, manipulative side to ‘finding a cure’: PR. It is becoming increasingly misleading and does a great disservice to the patients themselves. The ‘Cancer Ends With Me’ campaign, for instance, really does a disservice to people with cancer, who have the right to know how far off the cure is and what is and isn’t in their power to make that happen. It is an example of a campaign that is purely for the media’s gain and doesn’t achieve the goal of ending cancer anyway. While research is necessary now, profiteering PR is not.
Besides, the ‘cure’ being spoken of only targets a small proportion of individuals. It will be a long time before a cure for all can be spoken of. A vast amount of money is being spent on clinical trials worldwide on this quest for the Holy Grail of a cure. I think we need to be more realistic, because finding a cure will take many more years. It’s too soon to be investing so much time and effort into promoting it, especially as most of it goes on misleading PR which is detrimental and unhelpful to patients themselves. Health services should be altered to centre around the individual patient, and experts should be looking for long-term solutions such as the integrated model which targets behavioural and social health as well as physical health. We’re still left with third-rate health-services, even if a cure is found. The search for a rapid ‘solution’ isn’t improving health-services at all, which really should be the priority. Now more than ever is the time for patient-centred standards of health-services, especially for chronic conditions such as HIV. The HIV epidemic should ideally set an example for any future epidemics in terms of how to deal with it. Currently, it’s setting a very bad example. It’s a shame, because we already know how to do it better – it’s just a matter of convincing those higher up to take a logical solution on board.