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ethics

THE GLOBAL COMMUNITY:


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policy

Creating Models for HIV/AIDS


Prevention, Care, and Treatment

Children of HIV positive


parents play in a yard
By Kaylin Pennington outside an orphanage.

Can Community-Driven Treatment Programs Break Down Stigma and Fight HIV/AIDS?

I
n dozens of sub-Saharan African nations, the need decisions and investment resources to community groups
for HIV/AIDS treatment greatly exceeds available and local governments. The community-driven development
resources. The World Health Organization (WHO) model demonstrates that a more sustainable system of HIV/
estimated in a December 2004 report that 1.8 million AIDS prevention, care, and treatment can be created.
Zimbabweans have HIV—the virus that causes AIDS—and
less than 3% of the 300,000 people who need antiretroviral The Impact of HIV/AIDS
treatment have access to immediate care. With an estimated AIDSETI arose from the 2000 International AIDS
6,000 people dying of HIV/AIDS in Africa each day, the Conference in Durban, South Africa, and has since become

“Our community-driven model [has] not received a lot


of publicity because it’s flying against conventional
wisdom.” -Israelski
most pressing question is how to best distribute a limited an international network of twenty-six community-based
amount of antiretroviral medicine to the people who need it associations of People Living With HIV/AIDS (PLWHA).
the most. Through AIDSETI, Israelski and his colleagues have
Dennis Israelski, MD, Clinical Professor of Medicine in given nutritional support, psychological counseling, legal
Infectious Diseases and Geographic Medicine at the Stanford assistance, and financial aid by starting income-generating
University School of Medicine and Medical Director of AIDS activities to severely impacted communities. Ultimately, this
Empowerment and Treatment International (AIDSETI), approach affects the distribution of limited antiretroviral
has dedicated most of his career to addressing this problem. medicine by giving priority to people in the community who
He has developed a solution known as “community-driven actively promote HIV/AIDS prevention and treatment.
development”, an approach that gives control of planning Dr. Seble Kassaye, a postdoctoral fellow in infectious dis-

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ethics
+
policy “Community-driven development leads to an
empowered community. Through empowerment,
vibrant communities are created that can
overcome stigma and discrimination.” –Israelski
eases and member of Israelski’s research team, believes this The Biology of HIV/AIDS
model is effective because it works with the political, social,
and economic structures already in place now, and that it Is there a difference between HIV and AIDS? Yes. In
would be a mistake to “wait until Africa becomes like the simple terms, AIDS is the disease and HIV is the cause of
West.” The short-term solution of handing out medicine the disease. HIV—or human immunodeficiency virus—is
(the “top-down” approach, as Israelski has termed it) does the retrovirus (or “slow virus”) that attacks the immune
not address the crucial social and psychological issues that system, gradually compromising overall health. AIDS is
underlie the HIV/AIDS epidemic. Although the stigma that the term used for the final stage of HIV infection. An HIV
accompanies the disease is not as prevalent as it once was, positive patient is usually diagnosed with AIDS if the level
it remains a barrier that must be overcome. As an example, of crucial white blood cells (CD-4 cells) drops below 200;
Kassaye explains that it is not uncommon for a daughter to other symptoms include severe weight loss (known as
be relegated to the maids’ quarters if her family discovers “AIDS wasting syndrome”).
that she is HIV positive.
How does HIV cause illness? HIV spreads through blood,
The Effectiveness of Community Empowerment semen, vaginal fluids, and breast milk from the infected to
“Our community-driven model [has] not received a lot of the uninfected. Unprotected sexual intercourse and sharing
publicity because it’s flying against conventional wisdom,” drug needles are among the highest-risk behaviors. The
says Israelski. By giving members of a community the virus attacks specific lymphocytes called T-helper cells (also
responsibility to make their own decisions, international “T-cells” or “CD-4 cells”), takes them over, and multiplies.
healthcare organizations must relinquish some of their Like all viruses, HIV can replicate only inside cells; however
control. It will take time to break down this inherently HIV and other retroviruses use an enzyme called reverse
paternalistic relationship, since Israelski believes that the transcriptase to convert their RNA into DNA, which can
world system defaults into a top-down approach to health then be incorporated into the host cell’s genes. T-helper
care. cells play the central role in normal immune response, and
Kassaye believes that a country in which the government as they are destroyed other parts of the immune system fail
welcomes the community-driven model will be more to function. Most individuals who “die from AIDS” actually
prosperous than a country that questions the model and die from pneumonia, tuberculosis, or some other disease
continues to rely on distribution of antiretrovirals by various that took hold because the HIV-infected immune system
institutions. One of the best examples of this is in Burundi: could not adequately combat it.
despite more than ten years of civil unrest, there is nearly
universal access to antiretroviral treatment due to the nation’s Below: This map displays the prevalance of AIDS in various parts of the world:
transition to the community-driven method. “Empowered Africa is most heavily affected.
communities can
more effectively hold
their governments
accountable,” says
Photo Credit: http://en.wikipedia.org/wiki/AIDS_pandemic

Israelski.
Some opponents
of the community-
driven model say
that strict regulation
of HIV/AIDS drugs
is imporant in
helping to control
the rapid mutation
of the virus to drug-
resistant forms. The
biggest problem with
dispensing HIV/AIDS

58 stanford scientific
ethics
drugs to communities is that A false-color photograph of +
policy
the treatment regiment is not a T-cell infected with HIV.
strictly controlled to ensure
that no doses are skipped and there are enough
drugs to consistently last an infected person a lifetime.
Otherwise, the virus will mutate more quickly, creating
a bigger problem for the HIV/AIDS challenge of drug-
resistance.
However, Israelski believes that the community-
driven model is not as haphazard as other models and
organizations that simply try to get the drugs to Africa
and then deal with how to distribute them and potential
problems later. Many other models and organizations
prioritize saving lives, but at what cost for the future?
Israelski’s model has a focus that intends to make sure
the community understands why they are being given
these drugs, what the drugs mean, and why they need
Photo Credit: http://www.lbl.gov/Science-Articles/Archive/sb/July-2004/1_HIV.html
to be responsible for making sure they are administered
correctly. Israelski believes that communities will environment.”
be empowered when they are given the resources to help At the forefront of his future research is an evaluation
themselves solve their own problems. of the impact of coupling community-driven programs
“Community-driven development leads to an empowered with corporate initiatives focused on social responsibility.
community,” he explains. “Through empowerment, vibrant Other groups and organizations advocate community-based
communities are created that can overcome stigma and work, but none of their strategies are as rigorously defined
discrimination.” From his perspective, a few individuals who as the community-driven model. Israelski believes that a

The most pressing question is how to best distribute


a limited amount of antiretroviral medicine to the
people who need it the most.
are committed to bringing a community out of silence can community-driven model fits into a niche that could not
serve as a tipping point for the creation of sustainable HIV/ otherwise be filled. S
AIDS health care.
KAYLIN PENNINGTON is a sophomore majoring in Human Biology with
Prevention, Care, and Treatment of HIV/AIDS a possible concentration in International Health, Psychology, or
The central goal that continues to drive Israelski’s research Human Development/Performance. She hopes to eventually work
is determining the most cost-effective method of prevention, as a doctor overseas. She enjoys listening to music, running track,
care, and treatment of HIV/AIDS and other diseases. Israelski and spending time with friends and family.
was one of the founding members of the Worldwide AIDS
Coalition, a nonprofit group that, while not synonymous To Learn More:
with AIDSETI, hopes to function similarly as a mechanism Visit the AIDS Empowerment and Treatment International
to provide more service and resources to communities (AIDSETI) website: http://www.aidseti.org/
severely impacted by HIV/AIDS. Israelski calls it a “push- -Mission statement: To expand access to HIV/AIDS
pull” mechanism: “We will push [the necessary] resources treatment in resource-poor countries and work to empower
to groups in the field that are most effective at health service associations of People Living With HIV/AIDS (PLWHA with
delivery. In turn, these groups will pull the resources to where the knowledge, financial and pharmaceutical resources to
they can do the most good.” run their own holistic HIV treatment programs.
The challenge, Israelski says, is getting funding for
something so original. He points out an ironic paradox: Visit the Worldwide AIDS Coalition (WWAC) website:
“There is an international agenda to combat HIV/AIDS and http://fightaidsnow.org/home.html
other communicable diseases in the developing world, but -Mission statement: To facilitate consilience in global
the profits that accrue from such activities have generally efforts to scale up HIV/AIDS prevention, care, and treatment
returned to the North and West. There is an economy in resource-poor communities and serve as a vehicle for
being generated to find a solution to these great microbial donors to channel support to organizations in the fight
killers of our time, but little economic benefit from these against HIV/AIDS and related diseases.
efforts has been observed in the most resource-constrained

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