title: AIDS, individual behaviour and the unexplained remaining variation.
abstract: From the start of the AIDS pandemic, individual behaviour has been put forward, implicitly or explicitly, as the main explanatory concept for understanding the epidemiology of HIV infection and in particular for the rapid spread and high prevalence in sub-Saharan Africa. This has had enormous implications for the international response to AIDS and has heavily influenced public health policy and strategy and the design of prevention and care interventions at national, community and individual level. It is argued that individual behaviour alone cannot possibly account for the enormous variation in HIV prevalence between population groups, countries and regions and that the unexplained remaining variation has been neglected by the international AIDS community. Biological vulnerability to HIV due to seriously deficient immune systems has been ignored as a determinant of the high levels of infection in certain populations. This is in sharp contrast to well proven public health approaches to other infectious diseases. In particular, it is argued that poor nutrition and co-infection with the myriad of other diseases of poverty including tuberculosis, malaria, leishmaniasis and parasitic infections, have been neglected as root causes of susceptibility, infectiousness and high rates of transmission of HIV at the level of populations. Vulnerability in terms of non-biological factors such as labour migration, prostitution, exchange of sex for survival, population movements due to war and violence, has received some attention but the solutions proposed to these problems are also inappropriately focused on individual behaviour and suffer from the same neglect of economic and political root causes. As the foundation for the international community's response to the AIDS pandemic, explanations of HIV/AIDS epidemiology in terms of individual behaviour are not only grossly inadequate, they are highly stigmatising and may in some cases, be racist. They have diverted attention from poverty and powerlessness as root causes of vulnerability to infection and as such they are a waste of scarce resources. A return to a basic needs approach to all the diseases of poverty is nothing more than proven public health wisdom and experience. A sustainable and meaningful response to AIDS is simultaneously a sustainable and meaningful response to all the diseases of poverty. The obstacles to the adoption of this approach are economic and political and must be confronted at the level of international financial institutions, the globalisation of neoliberal economic systems, the growing power imbalances between and within nations and the undermining of democracy and national sovereignty. An alternative strategy for AIDS and the other diseases of poverty would build on macroeconomic reforms for a fair, rational and sustainable international economic order so that democratically elected governments may meet their people's basic needs, including health, without external interference.
authors: a 15 Chemin du Passeur , 1219 , Aire , Switzerland.
authors: Alison
authors: A
authors: Katz
keywords: AIDS; behaviour; gender; macroeconomics; population susceptibility; poverty; promiscuity; racism; social justice